HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 10 ED clinical records (Pt. #1) reviewed for pain assessments, the Hospital failed to ensure a complete pain assessment and reassessment was conducted.

Findings include:

1. On 4/21/2025, the Hospital's policy titled, "Organizational Patient Assessment/Reassessment Plan" (dated 5/2024) was reviewed and required, "The goal of the assessment/reassessment process is to provide the best care and treatment possible, taking into consideration the patient's physiological, psychological, social/environmental situation and needs across the continuum of care. In order to achieve this goal, the following processes are performed: A) Data is collected to assess/reassess the needs of the patient. B) Data is analyzed to determine the appropriate approach to meet the care of treatment needs. C) Patient needs are identified and prioritized. ...Assessment/Reassessment Criteria -Reassessments are performed by RNs and physicians when:
a) There is a change in the patient's status
b) There is a change in the patient's vital signs prior to discharge
c) As indicated by patient condition and/or treatment."

2. On 4/21/2025, the "Documentation Guidelines in Emergency Department" (dated 10/2024) was reviewed and required, "Pain assessment - Use a pain scale appropriate for age and/or condition, specify location of patient's pain, reassessment after intervention should include an appropriate pain scale with location, reassessment within 1 hour if pain score greater than 4 on 1-10 scale."

3. On 4/21/2025, Pt. #1's ED clinical record (dated 10/20/2025) was reviewed and indicated:

ED triage nurse's (E #1) notes (dated 10/20/24 at 8:57 PM) indicated, "Pt. #1 arrives with reports of increasing seizures; Pt. #1's [parent] reports Pt. #1 fell last week and has had arm and back pain since. Pt. #1 has a history of epilepsy. Pt. #1 had vomiting episodes x 2 on arrival. Approximately 20 second seizure prior to placement in bed; airway stayed protected; was able to place himself in the ED cot per himself per his request; able to position himself on the cot - placed in ED 16."

ED triage nurse's (E #2) notes (dated 10/20/2024 at 8:59 PM) indicated, "Pt. #1 arrived to ED via private vehicle, accompanied by Pt. #1's [parent], with complaints of back pain after experiencing multiple seizures last week and falling. Pt. #1's [parent] states Pt. #1 was also complained of right arm and chest pain. Pt. #1 states Pt. #1's right arm is broken and believes Pt. #1 may have an infection. Pain assessment scale used 0-10, pain score: 10 worst possible pain. While on the way to ED room, Pt. #1 began to seize in wheelchair for approximately 30 seconds. Pt. #1 was lowered to the ground and placed on cot. Pt. #1 had one bout of emesis after seizure. Pt. #1 had no postictal phase. Pt. #1 alert and oriented, per Pt. #1's baseline. E #2's notes at 9:35 PM indicated, "Pt. #1 had another seizure lasting approximately 10-15 seconds. Pt. #1 alert and oriented times four, per baseline and is maintaining a patent airway. Pt. #1 had no postictal (altered state of consciousness after an epileptic seizure) phase." There was no documentation in Pt. #1's clinical record regarding location or duration of Pt. #1's pain. There was no documentation of any pain reassessment in Pt. #1's clinical record.

ED provider (MD #1) notes dated 10/20/24 at 10:03 PM indicated, "Pt. #1 presented to the ER for chief complaint of seizures. On my assessment, Pt. #1 stated [Pt. #1 just needs something for seizures and that Pt. #1 does not want to be here anymore.] Pt. #1 states that Pt. #1 that Pt. #1 takes Pt. #1's medications as prescribed, just needs something to make the seizures stop. Review of symptoms - Neurological: positive for seizures, negative for light-headedness, numbness and headaches. Respiratory - Negative for choking, chest tightness and shortness of breath, HENT(head, eyes, ears, nose and throat) - Negative - Negative for congestion and dental problem. Physical exam - blood pressure 172/113, pulse 105, respirations 24, temperature 97.7 and spO2 98%. Cardiovascular - rate and rhythm: Normal rate and regular rhythm. Heart sounds: No murmur heard. Pulmonary: Effort - Pulmonary effort is normal. No respiratory distress. Breath sounds - normal breath sounds. Musculoskeletal - Cervical back - neck supple. Skin - General - skin is warm and dry. Neurological - Mental status - Pt. #1 alert and oriented to person, place, and time. Psychiatric - Mood and Affect - Mood normal. Behavior: Behavioral normal ...Clinical impression - Seizure ...Medical Decision Making - Pt. #1 feels comfortable plan for discharge, provide with Ativan (anti-anxiety medication) will be discharged home." There was no documentation in MD #1's notes regarding a pain assessment.

Pt. #1 was discharged at 10:06 PM on 10/20/2024.

4. On 4/22/2025 at 8:10 AM, an interview was conducted with the ED Director (E #6). E #6 stated that there should have been a reassessment within 1 hour if score greater than 4 on 1-10 scale. E #6 stated that the pain assessment should include location and duration of pain.