HospitalInspections.org

Based on review of medical records, staff interviews, patient interviews, and review of facility policy and procedures, it was determined that the facility failed to ensure: 1) pain is assessed and treated for one of 10 medical records (#1); 2) pain reassessments are completed in accordance with facility policy and procedure for six of 10 medical records (#2, #3, #4, #6, #8, and #9).

Findings include:

1. On 11/22/2023 at 10:00 AM, during medical record review for Patient (P)1 with Staff (S)4 (Emergency Department Manager), in the presence of S1, (Quality Improvement Specialist), S2, (Quality Improvement Specialist), and S3, (Chief Nursing Officer), the following was revealed:

On 11/06/2023 at 01:08 [1:08 AM], P1 presented to the ED [Emergency Department] with complaints of chest pain, left sided (below the breast area) pain, and lower back pain that radiates down to the left leg.

At 1:14 AM, P1's triage was started. There was no documented pain assessment.

At 2:26 AM, a MSE (Medical Screening Exam) was completed by the ED provider. The chief complaint documented was "chest pain and back pain." Review of the ED Provider Examination of P1 stated, "Review Of Systems ... Respiratory: Positive for shortness of breath. Negative for cough ...Cardiovascular: Positive for chest pain and leg swelling ... ." Documentation from the ED Provider identified P1 was positive for pain. There was no documented measurement of P1's pain level throughout his/her course in the ED, as outlined in the facilities "Pain Management" policy.

The Facility policy, "Pain Management" (10/2021) states, " ...when it has been determined that a patient is experiencing pain; a clinician further assesses factors impacting that pain experience. This includes the following:..Pain intensity is assessed...utilizing a validated assessment scale...a simple verbal scale of 0 to 10...0 is defined as "no pain" and 10 is defined as "sever pain...".

The facility "Nursing Documentation" (04/2022) policy states, " ...All assessments shall be available to all healthcare personnel involved in the care of the patient...Documentation in the EMR is performed by the appropriate disciplines involved in the patient's care...".

On 11/22/2023 at 10:05 AM, during an interview, S4 (ED Nurse Manager) stated, "when vital signs are done in the ED, the pain assessment is done at the same time." S4 confirmed that there was no documented evidence that a pain assessment was done in the ED for P1.

On 11/06/2023 at 05:29 [5:29 AM], P1 was admitted to the 5th floor nursing unit. P1's first pain assessment was not documented until 8:00 AM, at a 0/10 on the numeric pain rating scale. At 9:50 AM, P1's pain score was documented as a 7/10; "pain location: back, radiating towards the leg"; was described as "constant" and "aching, cramping, crushing, penetrating, nagging."

Review of the prescribed medications revealed an order for lidocaine (Lidoderm) 5% 1 Patch with a start date of 11/06/23 0515 [5:15 AM]. There was no documentation that P1 received the Lidocaine Patch ordered.

A nurse to doctor communication under the section titled, "Registered Nurse Progress Notes," dated 11/6/23 at 2:00 PM stated," ... PATIENT COMPLAIN OF RIB PAIN RADIATING TO THE LEFT LEG. DR. (NAME) NOTIFIED, WILL SEE THE PATIENT ...on 11/06/2023 at 15:50 [3:50 PM], it stated," ...DR. (NAME) CAME AND SPEAK TO THE PATIENT, THEN THE PATIENT GET UPSET [sic]. DO NOT WANT ANY DISCHARGEINSTRUCTION [sic] The SALINE LOCK REMOVED AND MONITOR. DO NOT ANY PAIN MEDICATIONS [sic]. LEFT AMBULATORY BY THE RN. NOT IN ACUTE DISTRESS ..." P1 was discharged on 11/6/23 at 4:18 PM.

An order was documented for oxycodone-acetaminophen (PERCOCET) 5-325 MG (milligrams) per tablet, 1 tablet, with a start date of 11/06/23 15:30 [3:30 PM]. There was no documention that P1 received the Percocet ordered. There was no documentation that P1 was provided any other pain medication during his/her hospital course.

On 11/22/23 at 11:55 AM, during an interview with S12 (Registered Nurse, 5th floor), he/she stated, "When a patient comes from the ER (Emergency Room), the process of admission to the unit starts with an overall assessment." S12 further stated, "an overall assessment consist of vital signs, pain assessment, body assessment, and identification of patient needs." S12 also stated, "if a patient is experiencing a pain level of seven (7), I would contact the doctor. If the primary is not available, we can call a resident for a one time order." S12 stated, "documentation on patients' charts are done throughout the shift. Every patient gets a pain assessment, every four hours for the Telemetry Unit."

The Facility policy, "Pain Management" (10/2021) states, " ...requires that pain be assessed in all locations where care is provided ...Pain is... personal... influenced to varying degrees by biological, psychological, and social factors ...A person's report of... pain should be respected ...pain is contingent upon appropriate pain assessment ...is subjective ...the patient is the best judge of the intensity and relief of pain ... ...presence of severe pain requires immediate attention and intervention..."

The Facility policy, "Patient Rights" (3/2023) states, " ...Every New Jersey hospital patient shall have the following rights...to appropriate assessment and treatment for pain ..."

The facility policy, "Nursing Documentation" (04/2022) states, " ...Required Documentation ...Vital signs and Pain Assessment ...assessed by the registered nurse, based on the patient's chief complaint ... ."

2. On 11/22/2023 at 11:45 AM, Medical Records (MR) two through 10, reviewed with S8 (Professional Development Department Specialist), revealed the following:

MR #2: Primary Problem: Closed Fracture of right hip, initial encounter. P2 had a pain assessment on 11/21/2023 at 20:00 [8:00 PM] with a reported pain level of 2/10. P2 was given acetaminophen extra strength 1000mg at 21:53 [9:53 PM]; no pain re-assessment done 1 hour post medication administration in accordance with facility policy.

MR #3: Primary Problem: Acute knee pain. P3 had a pain assessment on 11/21/2023 at 4:45 AM, with a reported pain level of 10/10. Morphine 6 mg IV (intravenous) Push given at 6:15 AM, Morphine 4 mg IV Push given at 7:25 AM; no pain re-assessment documented 1 hour post medication administrations in accordance with facility policy.

MR #4: Primary Problem: Osteomyelitis of left foot, unspecified type. P4 had a pain assessment on 11/20/2023 at 00:41 [12:41 AM], with a reported pain level of 4/10. Oxycodone 5 mg by mouth was given at 00:41 [12:41 AM]; no pain re-assessment documented 1 hour post medication administration in accordance with facility policy.

MR #6: Primary Problem: Numbness of both lower extremities. P6 had a pain assessment on 11/22/2023 at 10:36 [10:36 AM], with a reported pain level of 5/10. P6 was given acetaminophen 650 mg at 10:36 [10:36 AM]; no pain re-assessment documented 1 hour post medication administration in accordance with facility policy.

MR #8: Primary Problem: Acute pancreatitis, unspecified complication status, unspecified pancreatitis type. P8 had a pain assessment done on 11/20/2023 at 14:53 [2:53 PM], with a pain level of 8/10. P8 was given Fioricet, ESGIC 50-325-40 mg tablet at 17:42 [5:42 PM]. No pain re-assessment documented 1 hour post pain medication administration in accordance with facility policy.

MR #9: Primary Problem: Intractable headache. P9 had a pain assessment on 11/21/2023 at 09:36 [9:36 AM], with a pain level of 8/10. P9 was given Toradol injection 30 mg IV Push at 10:54 [10:54 AM]. No pain re-assessment done 1 hour post pain medication administration in accordance with facility policy.

The facility "Pain Management" (10/2021) policy states, "...Once an intervention is instituted to address pain needs, appropriate follow-up assessment is required...Pain reassessment is completed within a maximum of one hour following pain medication administration and is documented...".

The facility "Nursing Documentation" (04/2022) policy states, " ...Reassessment can be based on any of the following: their individualized need...plan of care...change in the patient's condition...the patient's diagnosis...desire for care, treatment, and services...".

Based on medical record review, staff interviews, review of policy and procedure, it was determined that the facility failed to ensure that patients participate in the development and implementation of his/her care plan.

Findings include:

On 11/22/2023 at 10:00 AM, during medical record review for Patient (P)1 with Staff (S)4 (Emergency Department Manager), in the presence of S1, (Quality Improvement Specialist), S2, (Quality Improvement Specialist), and S3, (Chief Nursing Officer), the following was revealed:

On 11/06/2023 at 01:08 [1:08 AM], Patient (P)1 presented to the Emergency Department (ED). with a chief complaint, documented in the "ED-specific reports" as the following: " ...Chief Complaint ...Chest pain ... Left side below breast area, started 11/04/2023, pain increased 11/05/2023 ...Lower Back Pain ...Radiates down left leg ...Patient roomed in ED ... To room C1-03 ... 01:14 [1:14 AM] ...". On the ED Provider Examination Note of P1, on 11/06/2023 at 2:26 AM, while in the ED, it was identified in S17, the Medical Doctor-ED Provider, under documentation of, "Review of Systems" that P1's, " ...Respiratory: Positive for shortness of breath. Negative for cough ...Cardiovascular: Positive for chest pain and leg swelling ...".
At 1:25 [1:25 AM], S16 (ED Registered Nurse) documented in the ED Triage Notes " ... c/o L [left] sided chest and back pain ...reports pain when taking a deep breath ... ."

A review of P1's Care Plan, generated on 11/06/ 2023 at 1221 [12:21 PM] by the interdisciplinary team, revealed implementation for problems associated with, " ...Mobility -Impaired ... ." There was no documented care plan generated during P1's stay for his/her chief complaints of shortness of breath, chest pain, or lower back pain radiating down his/her leg.

Review of P1's discharge education and instructions provided by the discharging nurse, revealed instructions for, " ...Mobility ...ambulation safety ...bed mobility ... ." There was no documentation of patient education for reported and documented problems of shortness of breath, chest pain, or lower back pain radiating down to his/her leg.

These findings were confirmed at 2:26 PM with S1, S2, S3, and S15 [via telephone], (Director of Patient Safety and Quality).

Facility policy, "Interdisciplinary Plan of Care" (11/2022) states, " ...Within 24 hours of admission, an individualized plan of care is designed ...The plan of care provides a mechanism for monitoring a patients progress ...The RN will initiate ...and work in collaboration with the multidisciplinary team, the patient, and ...utilizing information from the patient's admission history, physical assessment, the patient's admitting diagnosis, and physician orders ... ."