HospitalInspections.org

Based on hospital policy and procedure review, medical record review and staff interview, the nursing staff failed to assess pain per hospital policy for 5 of 10 sampled medical records reviewed. (Patient #1, #3, #7, #8 and #9)

Findings included:

Review on 09/18/2019 of the hospital policy and procedure titled "Pain Assessment and Management" revised 10/2018 revealed "Purpose: To establish guidelines for pain assessment and management for patients receiving nursing care ...Policy Statement: A. Patients have the right to appropriate assessment and management of pain ...C. Pain is assessed in all patients who receive nursing care, emergency care ...F. Assessment- Patients are assessed for presence or absence of pain by the RN (registered nurse) or LPN (licensed practical nurse): 1. Initial assessment-upon admission, ECC (emergency care center-the emergency department) triage...2. Ongoing re-assessments are based on patient's condition and responses to treatment..."

1. Review on 09/18/2019 of the closed medical record for Patient #1 revealed a 39-year-old female presented to the Emergency Department on 06/28/2019 at 1541 with a diagnosis of Suicidal Ideation and Depression. Review of the triage vital signs documented at 1546 revealed Temperature (T)-97.9, Pulse (P)-74, Respirations (R)-20, Blood Pressure (BP)-129/73, Oxygen (O2)-100%. Review of the medical record revealed no available documentation of an assessment of the patient's pain at triage or during Patient #1's hospitalization. Patient #1 was transferred to another hospital for inpatient psychiatric treatment on 06/30/2019 at 2040.

Interview on 09/19/2019 at 1209 with the Chief Nursing Officer (CNO) revealed the nursing staff were expected to perform a pain assessment per the hospitals pain assessment policy. Interview revealed the expectation was for nurses to assess pain during triage and reassess based on the patient's condition and response to pain interventions.

2. Review on 09/18/2019 of the closed medical record for Patient #3 revealed a 41-year-old female presented to the Emergency Department on 07/06/2019 at 1407 with a diagnosis of Suicidal Ideation, Depression, and Cocaine Abuse. Review of the triage vital signs documented at 1413 revealed T-98.8, P-70, R-18, BP-105/69, 02-100%. Review of the medical record revealed no available documentation of an assessment of the patient's pain at triage or during Patient #3's hospitalization. Patient #3 was transferred to another hospital for inpatient psychiatric treatment on 07/07/2019 at 0942.

Interview on 09/19/2019 at 1209 with the Chief Nursing Officer (CNO) revealed the nursing staff were expected to perform a pain assessment per the hospitals pain assessment policy. Interview revealed the expectation was for nurses to assess pain during triage and reassess based on the patient's condition and response to pain interventions.

3. Review on 09/19/2019 of the open medical record for Patient #7 revealed a 17-year-old female presented to the Emergency Department on 09/18/2019 at 1732 with a diagnosis of Depression and Hallucinations (a perception of having seen, heard, touched, tasted, or smelled something that wasn't there). Review of the triage vital signs documented at 1744 revealed T-98.1, P-90, R-16, BP-128/79, 02-99%. Review of the medical record revealed no available documentation of an assessment of the patient's pain at triage or during Patient #7's hospitalization.

Interview on 09/19/2019 at 1209 with the Chief Nursing Officer (CNO) revealed the nursing staff were expected to perform a pain assessment per the hospitals pain assessment policy. Interview revealed the expectation was for nurses to assess pain during triage and reassess based on the patient's condition and response to pain interventions.

4. Review on 09/19/2019 of the open medical record for Patient #8 revealed a 12-year-old male admitted presented to the Emergency Department on 09/18/2019 at 2120 with a diagnosis of Suicidal Ideation. Review of the triage vital signs at 2147 revealed T-98.2, P-88, R-20, BP-128/81, 02-99%. Review of the medical record revealed no available documentation of an assessment of the patient's pain at triage or during Patient #8's hospitalization.

Interview on 09/19/2019 at 1209 with the Chief Nursing Officer (CNO) revealed the nursing staff were expected to perform a pain assessment per the hospitals pain assessment policy. Interview revealed the expectation was for nurses to assess pain during triage and reassess based on the patient's condition and response to pain interventions.

5. Review on 09/19/2019 of the open medical record for Patient #9 revealed a 28-year-old male admitted presented to the Emergency Department on 09/13/2019 at 0124 with a diagnosis of Suicidal Ideation. Review of the triage vital signs at 0128 revealed T-98.1, P-95, R-18, BP-108/68, 02-97%. Review of the medical record revealed no available documentation of an assessment of the patient's pain at triage. Further review of the medical record revealed the only available documentation of an assessment of Patient #9's pain was on 09/19/2019 at 0830.

Interview on 09/19/2019 at 1209 with the Chief Nursing Officer (CNO) revealed the nursing staff were expected to perform a pain assessment per the hospitals pain assessment policy. Interview revealed the expectation was for nurses to assess pain during triage and reassess based on the patient's condition and response to pain interventions.

NC00153679