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Based on review of facility documents, medical record (MR), and staff interview (EMP), it was determined the facility failed to follow its established policy for evaluating and re-evaluating a patient's pain level regarding pain medication administration for one of one medical record reviewed (MR1).

Findings include:

Review on September 17, 2014, of the facility's "Patient Rights and Responsibilities" policies, last reviewed/revised September 26, 2013, revealed "Policy: At Robert Packer Hospital, we encourage respect for the patient's personal preferences and values of each individual. We consider the patient a partner in their hospital care. When a patient is well informed, participates in treatment decisions, and communicates openly with their doctor and other health professionals, they make their care as effective as possible. Hospital personnel, medical staff, and contracted staff performing patient care must observe these patients' rights. Procedure: The patient or patient's representative is informed of patient rights and responsibilities upon admission to the hospital or prior to the provision of outpatient services. These rights and responsibilities are displayed or posted as follows in designated registration areas in the hospital: Patient Rights: ... 27. You have the right to effective pain management. ..."

Review on September 17, 2014, of the facility's "Pain Management" policy, last reviewed/revised June 1, 2012, revealed "Policy: All admitted patients should be assessed for pain initially with admission assessment, and then subsequently thereafter according to assessment findings. Patients should receive treatment for pain relief as warranted and be monitored for effectiveness. Procedure: A. Assessment ... 2. When pain is identified, either acute or chronic, a more comprehensive assessment should be performed and pain management implemented in the patient's plan of care. ... 6. Pain intensity will be determined by the use of a pain-rating scale appropriate for the patient's stage of growth and development ability / 0 - 10 scale; ... 10. In general, effectiveness of PRN [as needed] pain medications and other interventions should occur within 30 - 90 minutes after administration, or when therapeutic effectiveness can be assessed. ..."

Review of MR1 on September 17, 2014, revealed the patient was admitted to the Emergency Department (ED) on December 25, 2013, with the complaint of worsening low back pain to the left hip with pain radiating down the left groin and leg. A magnetic resonance imaging (MRI) scan of the lumbar spine was performed and found MR1 to have degenerative disc disease of the lower lumbar spine.

Nursing documentation on December 25, 2013, at 9:03 PM revealed MR1's pain level was 10 on a scale of 0 - 10 [Zero represents no pain at all while 10 represents the worst imaginable pain]. The ED physician instructed nursing staff to administer Dilaudid (a narcotic pain medication) 2 mg (milligram) intravenous (IV). Further review revealed MR1's pain level continued at a level of 10. The ED physician instructed nursing staff to administer another dose of Dilaudid 2 mg IV at 9:25 PM. Continued review revealed no documentation nursing staff re-assessed MR1's pain following the administration of the second dose of Dilaudid for MR1's continued pain.

Interview with EMP1, EMP2, EMP4 and EMP5 on September 17, 2014, at approximately 2:30 PM confirmed MR1 was admitted to the facility's ED on December 25, 2013, for the complaint of worsening low back pain to the left hip with pain radiating down the left groin and leg; an MRI of the lumbar spine revealed the patient had degenerative disc disease of the lower lumbar spine; and nursing documented on December 25, 2013, at 9:03 PM that MR1's pain level was 10 on a scale of 0 - 10. Continued interview confirmed the ED physician instructed nursing staff to administer Dilaudid 2 mg IV, MR1's pain level continued at a level of 10; and the ED physician instructed nursing staff to administer another dose of Dilaudid 2 mg IV at 9:25 PM. Further interview with EMP3 and EMP4 confirmed there was no documentation the nursing staff re-assessed MR1's pain following the administration of the second dose of Dilaudid for MR1's continued pain.

2) Continued review of MR1 revealed nursing documentation on December 25, 2013, at 11:30 PM that nursing staff administered Dilaudid 2 mg IV at 11:31 PM. There was no documentation that nursing staff re-assessed MR1's pain level following the administration of the Dilaudid and prior to the patient's discharge from the ED on December 26, 2013, at 00:38 AM.

Interview with EMP4 and EMP5 on September 17, 2014, at approximately 3:10 PM confirmed nursing staff administered Dilaudid 2 mg IV at 11:31 PM on December 25, 2013, and there was no documentation that nursing staff re-assessed MR1's pain level following the administration of the Dilaudid and prior to the patient's discharge from the ED.

Based on review of facility documents, medical record (MR), and staff interview (EMP), it was determined the facility failed to ensure each patient presenting to the Emergency Department (ED) for evaluation and treatment was maintained on the facility's ED log for one of one medical record reviewed (MR1).

Findings include:

EMP1, EMP2, EMP4 and EMP5 were requested to provide a facility policy/procedure for maintaining the ED log. No policy/procedure was provided.

Review of the facility's "Triage and Nursing Assessment/Reassessment" policy, last revised November 12, 2013, revealed "Policy: Every patient presenting to the Emergency Department will be triaged by a RN [registered nurse] and then receive assessment / reassessment based on their needs as well as factors influencing patient flow through the system. Triage: 1. An ED Registered Nurse, Midlevel Provider or Physician will triage patients who present to the ED. 2. The ED utilizes the Emergency Severity Index (ESI) 5 level triage system. At minimum, a chief complaint, vital signs (VS), and pain level will be obtained and initial acuity/priority of care level will be documented for each ED patient based on the severity level and other relevant clinical information upon arrival to the ED. 3. When a treatment room is available, the patient may be taken directly to the room for the triage process to occur. Patients who are directed to a waiting area will be instructed to inform staff of any change in condition. ED staff will communicate with waiting patients or families to elicit changes in status and keep them updated on progress. 4. Staff will initiate appropriate nursing interventions based on ED triage and assessment. 5. Relevant ED orders may be instituted during this time with a physician order. 6. The Triage nurse will communicate relevant information to number of patients waiting, acuity of patients waiting, any changes in condition of patients waiting to the appropriate ED healthcare providers. Assessment / Reassessment: 1. Initial nursing assessment includes triage process as outlined above. 2. The initial assessment is specific to patient status and complaint. 3. The initial assessment at minimum includes chief complaint, VS and pain level as well as relevant clinical information. 4. The ED provider assessment and impression is documented as part of the patient's history and physical. 5. Additional clinical nursing assessment data is documented by exception and collected throughout the course of the ED visit and is based on acuity, presentation, changes in condition and treatment provided. 6. In general, reassessments are based on triage level (acuity and other relevant clinical information) as follows: a. Triage level 1 and 2 - hourly VS and pain level b. Triage level 3 - every 2hr VS and pain level c. Triage level 4 and 5 - VS and pain level as needed if change in condition and upon discharge (if not completed within past 60 minutes) 7. Reassessments will include relevant clinical information based on condition and treatments provided. 8. Results of reassessment and clinically significant findings are documented in the patient's medical record."

Review on September 17, 2014, of the facility's ED central registration log for August 8, 2014, revealed MR1's name. Further review revealed no documentation of MR1's time of arrival. There was no documentation an RN completed a triage assessment. There was no documentation of MR1's chief complaint, vital signs or pain level.

Interview with EMP1 and EMP2 on September 17, 2014, at approximately 1:45 PM confirmed MR1 came to the facility's ED on August 8, 2014; MR1's name was on the ED central registration log for August 8, 2014; and there was no documentation of MR1's time of arrival, a triage assessment by an RN, MR1's chief complaint, vital signs or pain level.

Interview with EMP3 on September 17, 2014, at approximately 2:45 PM confirmed MR1 came to the facility's ED on August 8, 2014; MR1's name was on the ED central registration log for August 8, 2014; and there was no documentation of MR1's time of arrival, that a triage assessment was completed by an RN, MR1's chief complaint, vital signs or pain level. Further interview revealed facility staff deleted MR1's ED visit information from the computer system after this patient left the ED without being seen by a physician.