HospitalInspections.org

Based on record review, staff interview, and review of hospital policies and procedures on 6/16/2014, the hospital failed to ensure that policies and procedures for pain assessment of patients presenting for medical care and treatment in the Emergency Department (ED) were followed by nursing staff for two patients (Pt #5 and #9) in a total sample of ten ED patients.

Findings include:

1.) Hospital policies and procedures related to pain assessment indicated that all patients presenting to the ED shall be questioned regarding pain. The assessment shall include the intensity of pain (using an age appropriate pain scale).

2.) For Pt #5, the Triage Note, dated 5/13/14 at 12:50 P.M., indicated the patient arrived to the ED and complained of left arm pain at the site of a fistula. The intensity of the pain was not documented, as required by policy.

3.) For Pt #9, the Triage Note, dated 5/13/14 at 1:24 P.M., indicated the patient arrived to the ED and complained of right leg pain. The intensity of the pain was not documented, as required by policy.