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Based on policy review, medical record reviews and staff interviews, the hospital staff failed to assess, reassess and manage pain for 5 of 14 patients reviewed for pain. (Pts #6, #10, #54, #58, #59)

The findings included:

Review on 02/24/2025 of the policy "Pain Management" last approved 10/2023 revealed "...Description. A. Describes expectations for assessment, treatment and reassessment of pain. B. Policy 1. Pain Assessment and Goals. a. ii. ... a Patient roomed in the emergency department (ED). Pain is assessed: A. At least once per encounter. (clinic or ED visit). iii. All care areas, Patients roomed in the ED. A. First report of pain. B. At any new report of pain, not previously addressed. (a new pain type, a new pain location). Also consider any family member reports of pain and/or behavioral manifestations consistent with pain. C. Immediately prior to administration of a PRN (as needed) pharmacologic or non-pharmacologic intervention to reduce pain. D. Within 5 to 60 minutes after administration of a PRN pharmacologic or non-pharmacologic intervention to reduce pain. ...E. Pain assessments and reassessments are documented in the electronic medical record..."

Closed medical record review, on 02/24/2025, revealed Patient (Pt) #6, an 86-year-old, arrived to the Emergency Department (ED) on 04/30/2024 at 1652 following a fall that occurred when the patient stood from the office chair and her "feet got caught in the wheels". Pt #6 sustained a right humeral shaft fracture (a break in a bone in the right upper arm). Pt #6 was placed in a coaptation splint (U shaped splint to immobilize the arm). Review of the pain evaluations revealed the last pain evaluation on 04/30/2024 was noted at 2130. Review revealed an order for Oxycodone (oral pain medicine for moderate to severe pain) 5 mg (milligrams) orally "once" on 05/01/2024 at 0330. The Medication Administration Record (MAR) revealed the medicine was given at 0334. Record review did not reveal a pain assessment or reassessment related to the oxycodone given. Record review revealed the next notation of a pain score was noted in Physical Therapy (PT) and Occupational Therapy (OT) evaluations, date and time of service 05/01/2024 at 0939 (6 hours after pain medication administration). The PT note indicated Pt #6 "...Endorsed 10/10 RUE (pain score 10 on a scale of 1 to 10 [where 10 is worst pain] right upper extremity) pain initially, improved to 7/10 following mobility." An OT note, date/time of service also 05/01/2024 at 0939, revealed "...Pain....reports 10/10 RUE," Review of the MAR revealed an order for Morphine (pain medication for moderate to severe pain) 4 mg (milligrams) IV "once" at 1049 and administered at 1110. No pain reassessment was noted. Review revealed an order on 05/01/2024 at 1742 for Oxycodone (oral pain medicine that treats moderate to severe pain) immediate release tablet 2.5 mg every six (6) hours prn (as needed) for three (3) occurrences . Review revealed 2.5 mg was given on 05/01/2024 at 2120, and on 05/02/2024 at 0419 and 1007. Review of pain assessments failed to find any assessments or reassessments of pain associated with the three oxycodone 2.5 mg doses given. MAR review revealed an order for Oxycodone 2.5 mg every 4 hours prn on 05/02/2024 at 1432 with a dose documented as given at 1521. No pain assessment or reassessment was noted until 2022 (almost six hours later) when the pain score was recorded as six (6).

Interview on 02/28/2025 at 1140 with the ED Director and Nurse Manager revealed medical providers assessed patients and wrote pain orders and then the nurses gave the medications. Interview revealed one time orders and scheduled pain medications did not require pain reassessment according to policy. The Director stated staff were trying to follow policy and do what they thought was right, and further indicated, "I think this is an opportunity for us."


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2. Closed medical record review on 02/18/2025 revealed Patient #10 presented to the ED on 10/10/2023 at 2011 with a chief complaint of acute back pain. Review revealed the patient had history of chronic back pain with an implanted spinal cord stimulator that was currently off. Record review revealed on 10/10/2023 at 2106 Patient #10 had a documented pain score of 9 (scoring used to describe intensity of pain whereby 10 is the most pain) and at 2122 an order for Dilaudid (medication used to treat pain) injection 0.5mg (milligrams, a unit of measure) once was ordered and at 2137 administration by RN #16. Review failed to reveal a reassessment pain score within 60 minutes of administration of pain medication. Review revealed on 10/11/2023 at 0206 through 10/12/2023 at 2125 an order was entered for Flexeril 10 mg tablet 3 times a day PRN (as needed) for muscle spasms. At 1100 the patient reported a pain score of 10 and Flexeril 10mg tablet was administered as ordered PRN. At 1113 Dilaudid injection 2mg once was ordered and at 1126 administration. Review failed to reveal a reassessment pain score within 60 minutes of administration of the pain medication. At 1400 the documented patient pain score was 0. At 1510 Dilaudid injection 2mg once was ordered and at 1555 administration. Review failed to reveal a reassessment pain score within 60 minutes of administration of pain medication. At 2028 the patient had a pain score was 6 out of 10. At 2103 Toradal (medication used to treat pain) 15mg injection was ordered and at 2115 administration. Review failed to reveal a documented reassessment pain score after Toradal administration. Review revealed the nursing staff failed to document completion of a pain reassessment after 4 medication administrations while the patient was in the emergency department.

Interview on 02/26/2025 at 1100 with an ED RN revealed it was the expectation of nursing staff to document reassessment of pain within 60 minutes after the administration of a pain medication.

Interview on 02/26/2025 at 1330 with the ED RN Director revealed it was the expectation of nursing staff to document reassessment of pain within 60 minutes after the administration of a pain medication.



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3. A closed medical record review on 02/25/2025 revealed Patient #54, a 76-year-old female who presented to Hospital A emergency department (ED) by private vehicle on 12/04/2024 at 1909 for complaints of chest pain. The Triage Note at 1910 by Registered Nurse (RN) #1 revealed "Seen here previously for similar. 7/10 chest pain (0 is no pain, 10 is the most severe pain) that began 1 hour PTA (prior to arrival). No previous heart hx (history)." An ESI (emergency severity index 3-urgent) was set to 3. Patient #54 returned to the ED waiting room. Review of the ED Patient Care Timeline at 2312 by RN #3 revealed "...No change in chief complaint and ESI." There was no pain reassessment documented (4 hours and 2 minutes). On 12/5/2024 at 0239 Patient #54 had reassessment by RN #3, " ... Reassessed: No change in chief complaint and ESI.) There was no pain reassessment documented. (6 hours and 29 minutes) At 0452 Patient #54 was transferred from the ED waiting room to an ED room. (8 hrs. and 43 min after arrival with no pain reassessment). At 0524 the MSE was completed by ED Resident MD #5. At 0553 ED RN #4 documented "Cardiac: Exceptions to WDL [within defined limits] (chest pressure). At 0647 ED Disposition was set to discharge by ED MD #5. Patient #54 had vital signs taken at 0700 by ED RN #6. No pain reassessment documented. 0725 Review of ED Quick Updates by RN #6 revealed "Pt. (patient) refusing to discharge until provider talks with her again." Record review revealed Patient #54 was discharged home on 12/05/2024 at 0729. The medical record review failed to reveal a pain reassessment from 12/04/2024 at 1910 through 12/05/2024 at 0725. (12 hours and 25 minutes).

Request to interview ED Discharge RN #6 revealed they were unavailable to interview.

Request to interview ED MD #5 revealed they were unavailable for interview.

Request to interview ED RN #3 revealed they were unavailable for interview.

Interview on 02/28/2025 at 1045 with the ED Director revealed "...I would have expected the nurse to document a pain level once the patient was roomed. Pain assessments should be completed with any intervention for pain. We see opportunities and plan to relook at the policy..." The interview revealed Patient #54 should have had a pain reassessment while in the ED.

4. A open medical review on 02/26/2025 revealed Patient #58, an 81-year-old male who presented to Hospital A emergency department (ED) on 02/24/2025 at 1648 with complaints of chest pain. The Triage Note at 1649 "Chest pain and shortness of breath. Afebrile. Atraumatic", with a pain assessment of 0/10 [0 is no pain, and 10 the most severe pain]. On 02/24/2025 at 1704 the ED Nurse Note revealed "Pt reports chest pain and SOB for last several days. 'For three days, ended up taking 3 doses of nitrogen." [sic] Helps with chest pain. Today chest pain started at 1430, but pain has resolved now. Reports feeling indigestion." An ESI 3 [urgent] was assigned, and Patient #58 was returned to the ED waiting room. On 02/24/2025 at 2113 Patient #58 was roomed in the ED. Review of nursing documentation at 2230 by RN #7 failed to reveal a pain reassessment. (5 hours and 26 minutes). On 02/25/2025 at 0557 the ED Disposition was set to admit. The medical record review failed to reveal a pain reassessment was completed 02/25/2025 1704 through 02/26/2025 at 0700 for Patient #58. (13 hours and 54 minutes). Patient #58 was admitted to an inpatient bed on 02/26/2025 at 1129.

Request to interview the ED RN #7 revealed they were unavailable for interview.

Interview on 02/28/2025 at 1045 with the ED Director revealed "...I would have expected the nurse to document a pain level once the patient was roomed. Pain assessments should be completed with any intervention for pain. We see opportunities and plan to relook at the policy..." The interview revealed Patient #58 should have had a pain assessment every shift by the RN.

5. A closed medical record review on 02/26/2025 revealed Patient #59, a 65-year-old male who presented to the emergency department (ED) on 02/24/2025 at 1815 via emergency medical services (EMS) with complaints of chest pain. Review of the Triage Note at 1821 by RN #19 revealed "Around 1730 severe chest pain, dizziness (doesn't feel like normal vertigo), with nausea. Pain still 10/10 (0 no pain, and 10 most severe pain). No emesis with EMS. ... Given 50 Fentanyl (an opioid medication used for pain) ..." At 1824 an ESI acuity of 3 [urgent] was assigned by the RN #24. At 1832, ED Quick Updates by RN #18 revealed "50 mcg (micrograms) of fentanyl (given IM (intramuscular) by EMS for total of 100 mcg given by EMS." At 1956 review of the ED Care Timeline revealed "ED Disposition set to LWBS [left without being seen] after triage." Review revealed on 02/24/2025 at 2315, (3 hours and 19 minutes later) Patient #59 had vital signs documented, and at 2324 ED RN #8 documented "ED Triage Reassess, No change in chief complaint and ESI." (no pain assessment documented on return to the ED) On 02/24/2025 at 2341 Patient #59 was roomed. At 0023 RN #20 completed a pain assessment of 4/10. Further review failed to reveal a pain reassessment was completed for Patient #59 02/25/2025 0024 through 02/25/2025 0724 (7 hours). Patient #59 was discharged home 02/25/2025 at 1627.

Request to interview ED RN #8 revealed they were unavailable for interview.

Request to interview ED RN #20 revealed they were unavailable for interview.

Interview on 02/28/2025 at 1045 with the ED Director revealed "..There should have been pain reassessed. We should have offered a pain intervention. ...We see opportunities and plan to relook at the policy..." The interview revealed an expectation for the nurse to complete a follow-up pain assessment for Patient #59's report of pain was not completed.

Based on policy review, medical record review and interview, hospital staff failed to provide lactose free food to 1 of 1 patients reviewed with a lactose intolerance. (Pt #6)

The findings included:

Review of a policy titled "Patient Diet Orders, Meal Orders, and Meal Frequency," effective 07/2021, revealed "...The Nutrition and Food Services.... Department will prepare and deliver meals to patients in accordance with the diet order....Diet orders indicate the type of food....to be provided to patients during hospitalization....Diet orders....are entered into the Electronic Medical Record (EPIC) by a provider....The patient's diet order interfaces from (name of the Electronic Medical Record system) to the computerized meal ordering system.... Dietary restrictions, allergens, and nutrients are built into (name of computerized meal ordering system) to ensure patients receive appropriate foods in accordance with their therapeutic diet. ..." Review of the policy did not reveal specific information about food intolerances or patients in the emergency department.

Medical record review, on 02/24/2025, revealed a physician order, dated 05/01/2024 at 1740, which noted "Nutrition Therapy Regular/House" diet along with "...Comments Lactose intolerant!" Review of an "ED Progress Note," date of service 05/02/2024 at 1021, revealed "...Pt has been eating well in general prior to hospitalization, but reports she doesn't like the food. She reports she was served a meal 'finally and it had cheese on it and I'm lactose intolerant.'" Record review revealed the previous diet order was discontinued and a new order was entered for "Nutrition Therapy Regular/Lactose Restricted" on 05/02/2024 at 1035.

Interview with Dietician #21, on 02/25/2025 at 1130 revealed the first nutrition order was an incorrect order. For a lactose intolerant diet, Dietician #21 indicated, the order should specify lactose free/ lactose restricted rather than be noted as a comment under a regular diet order. Interview revealed allergies and specific diet orders crossed over from the hospital electronic medical record system (EMR) to the computerized meal ordering system used by the Food and Nutrition Department to fill diet orders. Interview revealed any notes made in the "comments" section of the order did not cross over from the hospital EMR to the meal ordering system and would not be seen by dietary when filling nutrition orders.

Telephone interview on 02/27/2025 at 1500 with MD #22, a Resident who placed the first diet order revealed MD #22 had never been notified that using "comments" to indicate lactose intolerance was not an appropriate way to order for it. MD #23, a physician on the interview call, revealed the thought that "most of us would have done the same thing."

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