HospitalInspections.org

Based on policy review, record review and interview, the hospital failed to ensure nursing services took steps to manage patients' pain and reassessed pain levels timely for 1 of 3 (Patient #1) sampled patients reviewed.

The findings included:


1. Review of the hospital's Pain Assessment Policy dated 6/2020 revealed, "...POLICY: All patients will be assessed for pain based upon their clinical presentation, services sought, and in accordance with the care, treatment, and services provided. When pain is identified, the patient is treated...PURPOSE: The identification and treatment of pain is an important part of the plan of care because unrelieved pain had adverse physical and psychological effects...Pain Assessment Frequency...If pain medication is administered, patients will be reassessed for intensity of pain or sleeping within 2 hours...PAIN ASSESSMENT TOOLS Numeric Rating Scale...0 No Pain...1-3 Mild Pain...4-7 Moderate Pain...8-10 Severe Pain..."

Review of Patient #1's medical record revealed Patient #1 was brought to the ED (Emergency Department) on 11/25/2020 at 6:32 PM with a diagnosis of ALS (Amyotrophic Lateral Sclerosis). This chief complaint of Patient #1 was due to a left portacath placed on Friday 11/20/2020 (6 days earlier). The portacath site was warm, drainage noted with erythema and painful.

Review of the medical record revealed Patient #1 complained of pain in the ED on 11/25/2020 at 8:09 PM. His pain was assessed as a 5 out of 10 and at 10:22 PM. His pain was assessed as a 3 out of 10.
There was no documentation Patient #1 received pain medication after complaining of pain 2 times in the ED.

There was no documentation the physician was notified and no orders for pain medication were obtained from the physician.

Review of a Physician's order dated 11/26/2020 at 12:19 AM revealed, "...acetaminophen-HYDROcodone 325 mg [milligram]-5mg oral tablet...Order Details: hydrocodone bitartrate 5mg/ 1 Tab. [tablet]..PO [by mouth], q6h, [every 6 hours] PRN [as needed] Pain, Moderate (4-7)..."

Review of a Physician's order dated 11/26/2020 at 12:39 AM revealed, "...acetaminophen 325 mg Tab...Order Details: 650 mg = 2 tab...PO, q6h, PRN Pain, Mild or Headache..."

Patient #1 was discharged from the ED and admitted as an inpatient on 11/26/2020 at 12:49 AM.

Patient #1 complained of pain on 11/28/2020 at 10:43 PM. Patient #1's pain was assessed as a 4 out of 10. (Moderate Pain)
Review of Patient #1's Medication Administration Record (MAR) revealed Acetaminophen 650 mg administered on 11/28/2020 at 10:43 PM.
There was no documentation Patient #1's pain level was reassessed for effectiveness after the pain medication was administered.

Patient #1 complained of pain on 11/29/2020 at 12:12 PM. Patient #1's pain was assessed as a 5 out of 10. (Moderate Pain). No pain medication was given. The pain interventions documented were repositioning, breathing exercises, cold application, and relaxation techniques. Patient #1's skin on the left chest was red and blistery. The non pharmaceutical interventions were not assessed for effectiveness within 2 hours. Patient was discharged home and left the hospital on 11/29/2020 at 3:09 PM.

During a telephone interview on 10/1/2021 beginning at 4:00 PM, Patient #1's daughter stated Patient #1 was in pain and was not given pain medication when Patient #1 complained of pain. Patient #1's daughter stated Patient #1 left the hospital in pain.

Interview on 10/4/2021 beginning at 9:30 AM the Accreditation Officer was asked why Patient #1 was given Tylenol and not the stronger pain medication ordered on 11/28/2020 at 10:43 PM. The Accreditation Officer stated they give the lesser strength as long as the pain is reassessed and the pain is less than when the medication was given. (Patient #1's pain was not reassessed).

During a telephone exit conference with the Director of Risk Management (DRM) on 10/22/2021 beginning at 4:19 PM, the DRM stated they (ED Physicians) typically do not give pain medications in the ED until the physicians can determine the reason the patient was seeking care in case it was cardiac.