HospitalInspections.org

Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure that: 1) the patient's right to have pain managed and treated is performed in accordance with facility policy; and 2) pain assessments include pain level in accordance with facility policy.

Findings include:

1. Facility policy titled, "Rights, Patient's Bill of ADM.044 *IHN*" REVIEW Date: 03/09/2023 states, " ...III. Procedure [:] ...(a) Every New Jersey hospital patient shall have the following rights ...These rights shall include at least the following: ...31. To expect and receive appropriate assessment, management and treatment of pain as an integral component of that person's care, in accordance with N.J.A.C. 8.43E-6. ..."

On 12/10/24 at 2:02 PM, Patient (P)1's medical record was reviewed with Staff (S)10, a Registered Nurse, and revealed the following:

On 10/22/24 at 18:13 (6:13 PM), P1 arrived at the Emergency Department (ED). He/she was triaged at 18:21 (6:21 PM) with a Chief Complaint of "right sided flank pain" and assigned an ESI (Emergency Severity Index) level (triage level) of 3H. During triage, an initial pain assessment was obtained, with a numerical pain score of 10/10 (10 out of 10).

On 10/22/24 at 21:34 (9:34 PM), an "ED Note Physician Note" by S11 (Physician Assistant) documented the following: " ... Treatment and Disposition [:] ...Patient ...coming to the ER [emergency room] complaining of severe right upper abdominal pain that started at noon today. No trauma injury. States that [he/she] feels 5 out of 10 pain worse with deep breathing and palpitation. ... I went out to the waiting room evaluated patient in the triage room, ordered labs [laboratory studies] imaging IV [intravenous] medication. ... went out and told the front desk that I do believe [he/she] needs an IV and medication for [his/her] symptoms they did tell me that IV placement cannot be done in the waiting room therefore I told them to please bring [him/her] back as soon as possible. ..."

P1 was brought back from the waiting room into room ED26 at 22:29 (10:29 PM), 4 hours and 1 minute after first report of pain, and 55 minutes after S11's assessment. The "ED Physician Note" on 10/22/24 by S11 further stated, " ...Treatment and Disposition [:] ... Patient was brought back into the room and I was called immediately by the nursing that patient is angry and does not want the IV placed. I go to the room [he/she] states that Motrin is not going to help [him/her]. I told [him/her] that I did order Toradol but we can change the medication to something stronger, at this time [he/she] was refusing the imaging and IV. Patient asks me multiple times what [his/her] diagnosis is I do explain to [him/her] that I do not have a diagnosis as of yet I do go over the ultrasound results with [him/her] saying that ...I do need further imaging ... [He/She] is very upset that [he/she] believes we brought back other people into the emergency room before [him/her], I do apologize and explained that I did try to get things started earlier in the waiting room, I did speak to the nurses about bringing [him/her] back sooner. Patient states that [he/she] does not want the IV [he/she] is just going to pull without [sic] [it out] [and] go to another hospital. I do try to alleviate the situation I do offer to give [him/her] a dose of morphine for [his/her] pain as well as the nurses at bedside attempting to put the IV line as we speak however [he/she] refuses. I did leave the room and [he/she] told the nurse [he/she] went [sic] to leave, refuses to sign any AMA [Against Medical Advice] forms. ..."

"ED Note Nursing," dated 10/22/24 at 23:23 (11:23 PM) stated, " ...Pt [patient] was just brought back from the waiting room about 15 minutes prior when [husband/wife] came to this RN to speak with Manager. ...Told I would come to get an IV started, draw blood and give Toradol. ... Patient asked what pain meds [medications] I was giving and told [him/her] Toradol. Patient refused and said [he/she] needed to speak with the PA. Told PA [S11] who came and explained to patient that we need to get IV and do the scans to figure out what is causing [his/her] flank pain. PA left and then the patient stated [he/she] is leaving AMA with [husband/wife]. Did not want to speak with PA or doctor again nor sign any AMA forms ..."

The medical record lacked documentation that P1's pain was managed and treated for over four hours after assessment.

These findings were confirmed with S10 on 12/10/24 at 2:24 PM.



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2. Facility policy titled "Vital Signs," last reviewed 10/04/2021, states, " ...Procedure: A. All patients presenting to the Emergency Department/S.E.D. [satellite emergency department] will have vital signs taken as part of the triage assessment. Additional vital signs will be taken for re-assessment at a minimum of four (4) hours and at time of discharge. ... F. Abnormal vital signs including pain level, will be rechecked at intervals appropriate to the abnormality and the patient condition as determined by the Triage/Primary nurse or the responsible physician. G. Complete vital signs will include temperature, pulse, respiration, blood pressure, pulse ox, and pain assessment ..."

On 12/10/24 at 2:37 PM, medical record review of P6 was conducted with S5, Regional Manager of Accreditation and Regulatory Affairs, and revealed the following:

On 9/12/24 at 6:27 PM, P6 presented to the ED with a chief complaint of right lower back pain that radiates to the hip.

At 6:30 PM, P6 was triaged. The RN documented "yes" next to "pain present" in the triage assessment. No pain rating scale or level was documented. At 10:56 PM, P6 received Toradol 30mg IV (30 milligrams intravenous) for pain, with a documented pain level of 7 out of 10. At 1:56 AM, when P6 was discharged to home, the RN documented "yes" next to "pain present." No pain rating scale or level was documented following the patient's reported pain level of 7 out of 10, or as part of a complete set of vital signs, at the time of discharge.

On 12/10/24 at 2:34 PM, medical record review of P10 was conducted with S6, and revealed the following:

On 11/24/24 at 2:03 PM, P10 arrived at the ED with a complaint of right upper quadrant abdominal pain. At 2:04 PM, P10 was triaged by a RN with a pain assessment documented as "10 = Worst possible pain/Severe." At 3:54 AM, P10 was administered 4mg IV morphine (a narcotic) for pain. At 6:15 PM, an RN documented P10 had "pain present," and at 6:16 PM, P10 was discharged to home. No pain rating scale or level was documented as part of a complete set of vital signs, at the time of discharge.

On 12/10/24 at 3:38 PM, findings for P6 and P10 were confirmed by S3, System Director of Regulatory and Accreditation