HospitalInspections.org

A. Based on document review and interview, it was determined that for 1 of 3 records (Pt. #1) reviewed for pain management, the Hospital failed to include the details of the pain assessed and failed to ensure timely interventions were implemented.

Findings include:

1. The Hospital's policy titled, "Pain Management Policy" (approved 11/24/2023), was reviewed and required, "Assessment of pain includes, but is not limited to: a. Location, b. Intensity, c. Quality, d. Frequency, e. Precipitating factors... Clinicians shall respond promptly to a patient's report of pain..."

2. The clinical record of Pt. #1 was reviewed on 01/30/2024. Pt. #1 was presented to the Hospital's emergency department (ED) on 12/27/2023, with a chief complaint of sore throat with fever.
- The Nursing Triage Assessment, dated 12/27/2023 at 10:44 AM, indicated that Pt. #1 reported moderate pain rated at 5 (based on a pain scale from 0-10; 0 = no pain and 10 = worst pain); however, the record lacked documentation of the location, type, and other details of the pain reported.
- The Medication Administration Record (MAR) indicated that Pt. #1 did not receive any interventions for pain until 12/27/2023 at 12:48 PM, over 2 hours later after the initial pain assessment. The record lacked documentation if Pt. #1 was offered pain relief at the time of the initial assessment.

3. An interview was conducted the Associate Director of ED (E#2) on 01/30/2024, at approximately 1:34 PM. E#2 stated that pain assessments in general are completed when the patients come into triage, and again when they come back to the station. E#2 stated that the patient should be assessed again before giving any pain medication and again an hour after administering pain medication. E#2 stated that the patient's rating, location of the pain, intensity, etc. should be documented with each pain assessment. E#2 stated that the patient should be asked if they are satisfied with the pain level, and document that or any refusal of pain interventions in the record.

B. Based on document review and interview, it was determined that for 1 of 5 records (Pt. #1) reviewed for intravenous (IV) line care, the Hospital failed to ensure that assessments were completed as required.

Findings include:

1. The Hospital's policy titled, "Nursing Documentation of Inpatient Care" (approved 12/26/2023), was reviewed and required, "Appendix C: General Units Nursing Documentation Requirements: ...Lines/Drains: ...Upon Initiation/Discontinuation..."

2. The clinical record of Pt. #1 was reviewed on 01/30/2024. Pt. #1 was admitted to the Hospital on 12/27/2023, with a diagnosis of pneumonia (lung infection). Pt. #1 had an IV placed in the right arm on 12/27/2023, at approximately 12:50 PM. The record indicated that the IV was removed on 12/30/2023 at the time of discharge (approximately 4:40 PM); however, the record lacked documentation of an assessment of the IV site at the time of discontinuation.

3. A telephone interview was conducted with Registered Nurse (E#8) on 01/30/2024, at approximately 2:17 PM. E#8 stated that IV sites should be assessed and documented every 8 hours and at the initiation and discontinuation.