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Based on record review, policy review, and staff interview it was determined the facility failed to ensure the nursing staff complied with facility policies related to the reassessment of pain for one (#3) of seven patients treated in the Emergency Department, of a total sample of 12 patients.

Findings included:

The Triage Notes dated 12/3/17 at 1:38 p.m. indicated Patient #3 presented to the Emergency Department (ED) complaining of pain. The notes included Patient #3 reported the pain was 10 on a scale of zero to 10, indicating the patient was experiencing severe pain at the time of arrival. The Triage Notes indicated Patient #3 was assigned an ESI (Emergency Services Indicator) acuity score of 3, indicating the patient had a condition requiring urgent medical attention.

The Nurses Notes dated 12/3/17 at 2:00 p.m. included an entry the patient was reporting lower abdominal pain and cramping. The Nurses Notes dated 12/3/17 at 4:36 p.m. indicated Patient #3 departed the ED at 4:36 p.m. on 12/3/17. The detailed review of the entire emergency department record failed to reveal any evidence of Patient #3's pain being reassessed or that the pain was relieved prior to departing the ED.

The policy entitled Assessment/Reassessment specified patient reassessment was to be performed at intervals according to the assigned acuity level: 1 = continuous assessment; 2 = minimum 1 hour or as condition indicates; 3 = minimum every 2 hours or as condition indicates; 4 = prior to disposition or as condition indicates; 5 = prior to disposition.

A telephone interview was conducted with Patient #3 on 1/26/18 at 1:30 p.m. Patient #3 indicated she was in severe pain at the time she departed the ED on 12/3/17. She stated she walked out bent over and unable to stand up straight due to the pain in her lower abdomen.

The Director of Risk Management confirmed the finding Patient #3's pain was not reassessed in compliance with facility policies in an interview conducted on 1/26/18 at 2:30 p.m.