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Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to re-assess patients pain in the Emergency Department (ED) as per facility policy for four of twenty-one (21) medical records reviewed (MR1, MR12, MR13, MR14).

Findings include:

Review on July 22, 2025, of facility, " Pain Management Policy," published date March 7, 2025, revealed " I. Purpose: A. The purpose of this policy is to guide the treatment of pain. II. Policy: A. A patient ' s pain level will be assessed and reassessed, and the patients and their family will be taught pain management on an ongoing basis. (Admission, treatment and discharge). Patient/family education is documented in the medical record ... C. Interventions may be pharmacological or non-pharmacological, such as ice, heat, elevation, repositioning, relaxation techniques, distraction, massage or deep breathing. III. Procedures: ... F. Document specific intervention/s on the Electron Medical Record that either improve patient comfort or were ot effective.... G. Re-assess the level of pain after intervention using the same pain rating scale used for initial assessment. Timing of re-assessment: 1. Within 30 minutes for parental intervention. 2. 60 minutes for oral analgesic 3. If the intervention is effective, continue to monitor patient. 4. If the intervention is ineffective, report to the Physician using the appropriate scale and evaluate other options: Example: Comfort measures, patient plan of care, medications, physician notification. 5. Document any additional information in the patient ' s medical record. ... "

Review of MR1 on July 22, 2025, revealed this patient presented to the ED on June 5, 2025, at 1604 by their OBGYN to rule out an ectopic pregnancy. MR1 was assessed and met the Acuity level of 2. MR1 reported a pain level of 8, on a scale of 1 to 10 with 10 being the worst pain, in their bilateral lower abdomen and was administered Tylenol 1000 milligrams (mg) by mouth for pain at 1851.

There was no documentation in MR1 indicating the facility re-evaluated this patient's pain level after 60 minutes.

Interview on July 22, 2025, with EMP1, confirmed the above findings.

Review of MR12 on July 22, 2025, revealed this patient presented to the ED on July 18, 2025, at 1136, with a chief complaint of being kicked in the abdomen. Documentation revealed MR12 was 8 weeks pregnant and was experiencing lower abdominal pain. MR12 was assessed and met the Acuity level of 3. MR12 reported a pain level of 6, on a scale of 1 to 10 with 10 being the worst pain, with moderate cramping pain in the lower abdomen. MR12 was discharged home on July 18, 2025, at 1645. There was no documentation in MR12 indicating nursing staff provided any pain interventions for this patient ' s pain rating of 6. There was no re-evaluation of MR12's pain level of 6 for five hours while the patient was in the ED.

Review of MR13 on July 22, 2025, revealed this patient presented to the ED on July 20, 2025, at 1518, with a chief complaint of abdominal pain. MR13 was assessed and met the Acuity level of 3. MR13 reported a pain level of 5, on a scale of 1 to 10 with 10 being the worst pain, with moderate pain of the lower abdomen. MR13 was discharged home on July 20, 2025, at 1844. There was no documentation in MR13 indicating nursing staff provided any pain interventions for this patient ' s pain rating of 5. There was no re-evaluation of MR13's pain level of 5 for 3.5 hours while the patient was in the ED.

Review of MR14 on July 22, 2025, revealed this patient presented to the ED on July 16, 2025, at 1406. MR14 was sent from the physician office for dehydration, compliant of chills, nausea and a severe sunburn. MR14 was assessed and met the Acuity level of 3. MR14 reported a pain level of 7, on a scale of 1 to 10 with 10 being the worst pain, with generalized pain and burning of the sunburn. MR14 was discharged home on July 16, 2025, at 1722. There was no documentation in MR14 indicating nursing staff provided any pain interventions for this patient ' s pain rating of 7. There was no re-evaluation of MR14's pain level of 7 for three hours while the patient was in the ED.

Interview on July 22, 2025, with EMP3, confirmed the above findings.