HospitalInspections.org

Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure that pain is assessed and reassessed in accordance with facility policy, in four of seven Patients (P) (P1, P5, P7 and P9).

Findings include:

Facility Policy titled, "Pain Assessment and Management" revised 6/24, stated, " ... POLICY 1. All patients will be assessed for pain upon admission to the hospital and every shift. 2. All admitted patients will be assessed/reassessed for pain: ... 4. All patients will be reassessed as follows: a. Pain will be reassessed after each pain management intervention. ... Documentation should include the patient's response to the intervention and any side effects or adverse response. B. Exception: If a patient is sleeping comfortably, the patient should not be awakened for assessment or reassessment of pain. Document patient asleep. c. Patients receiving pain medications by any route noted in (a) and (b) above will be reassessed immediately prior to discharge. ..."

On 11/20/25, medical record review was conducted with S10, and the following was revealed:

Patient (P)1 arrived at the ED on 7/4/25 at 3:58 PM, with an arrival complaint of shoulder injury. At 5:04 PM, P1 reported four out of 10 pain on the numerical pain scale and was given Toradol 30 mg (milligrams) IM (intramuscularly). P1's medical record lacked evidence that a pain reassessment was completed after the administration of pain medication.

P5 arrived at the ED on 7/5/25 at 8:31 AM, with an arrival complaint of fall, back, shoulder pain. At 8:40 AM, P5's triage was completed and lacked evidence of a documented pain assessment. At 12:58 PM, P5 was discharged and lacked evidence that a pain assessment was completed upon discharge.

P7 arrived at the ED on 9/7/25 at 6:55 PM, with an arrival complaint of MVA (motor vehicle accident) and neck pain. At 8:08 PM, P7 reported 8 out of 10 pain on the numerical pain scale and was given Ibuprofen 100 mg/5 ml orally. P7's medical record lacked evidence that a pain reassessment was completed after administration of pain medication.

P9 arrived at the ED on 9/1/25 at 6:13 AM, with chief complaint of alcohol intoxication, fall, knee pain, and knee injury. At 1:57 PM, P9 reported 10 out of 10 pain on the numerical scale and was given Fentanyl 100 mcg (micrograms) IV (intravenously). P9's medical record lacked evidence that a pain reassessment was completed after administration of pain medication.

On 11/20/25 at 1:10 PM, upon interview with Staff (S)10, he/she confirmed the above policy applies to the Emergency Department (ED). S10 stated that pain assessments are to be completed upon initial triage and reassessed upon discharge. S10 further stated that pain assessment are to be completed when pain medication is being administered. S10 indicated pain reassessment are to be completed within one hour of administration of pain medication regardless of the medication route.

The above findings were confirmed with S10 during medical record review.