HospitalInspections.org

Based on review of medical records (Patient (P) 1, and P11), review of facility policy and procedure and staff interviews, it was determined the facility failed to ensure the patient's right to have their pain assessed and managed.

Facility policy titled "Pain Assessment/Management", effective 1/10/2023, states, " ... Procedure: 1. Emergency Department (ED) Pain Assessment a. Personnel: The ED nurses will work in conjunction with the practitioners to evaluate a patient's level of pain and implement non-pharmacological as well as pharmacological treatments to alleviate or lessen the pain. ...c. Pain will be assessed initially and routinely. This pain assessment will be documented in the medical record. The nurse will escalate a report of new or different pain. D. If pain is present, assessment may include but is not limited to: location, rating, description, pain, indicators, scale used, and interventions implemented, as appropriate for the patient. ... f. Appropriate pain management is offered based on clinical evaluation. When necessary, the practitioner may choose to prescribe pharmacological therapy to treat the patient's pain. ...4. Reassessment of Pain a. After the administration of pharmacological and/or non-pharmacological interventions, a reassessment is completed within 60 minutes. B. After the administration of Opioids, a reassessment and respiratory rate are completed within 60 minutes. ..."

Facility policy titled "Emergency Department Triage," effective 12/27/2022, states, " ...Procedure: 1. Quick Triage: ...a. Components of quick triage include: ...ii. Vital Signs/Pain ...Age appropriate Pain scale is utilized. ...

Facility policy titled "Patient Rights and Responsibilities," effective 7/26/2024, states, " ... Procedure: ...The patient has the right to a concerned team committed to pain relief and prevention and 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 10/10/24 at 10:15 AM, P1's medical record was reviewed. Review of the ED timeline indicated P1 presented to the facility's ED on 6/13/24 at 2:55 AM with a chief complaint of "Drug Overdose/Psychiatric Evaluation." P1 was brought to the facility via EMS and reported taking pills, however did not know what they were. P1's initial pain assessment was complete at 2:59AM and P1 rated his/her pain as 0-No pain. At 4:40 AM, P1 had an episode of PTSD, where he/she was aggressive and threatening to staff, had to be restrained, and was given IM [intramuscular] medications to calm him/her down. At 5:10 AM, P1 was placed in 4 point locked restraints which were removed at approximately 8:33 AM, when the patient's behaviors subsided. P1's medical record does not contain any record of any injuries being sustained during these events. P1 was seen by the crisis counselor on 6/13/24 at 10:28 AM. The Crisis Progress Note from 6/13/24 at 10:28 AM states, " ...Met with patient, who is now calm and cooperative. Pending final disposition. Patient expressed back pain 9/10- informed medical team of same." The ED timeline states, " ...12:27:46 [12:27 PM] Orders Placed; Medications- acetaminophen (TYLENOL) tablet 975 mg [milligram]; ibuprofen tablet 60 mg ...". P1 received both the 975 mg Tylenol and 600 mg ibuprofen by mouth at 12:36 PM. Review of P1's medical record lacked evidence of a pain assessment completed before the medications were given or a pain reassessment done after the medications were given.

On 10/10/24 at 2:15 PM, a review of P1's medical record was conducted in the presence of S6 (ED Nurse Manager) and S24 (ED Educator). The orders for the pain medications administered to P1 on 6/13/24 were reviewed with S24. S24 confirmed a pain assessment was not completed before or after the medications were given to P1. When asked if a pain assessment should have been completed, S24 stated, "a patient's pain should be reassessed with any changes in condition."

On 10/10/24, at 11:00 AM, P11's medical record was reviewed. Review of the ED timeline indicated P11 presented to the facility's ED on 4/29/24 at 6:51 PM, with a chief complaint of "Cyst." At 7:00 PM, the 'Chief Complaints Updated,' stated, "Cyst (on left side back x 1 week, pain increasing, denies fevers)." At 7:00 PM, P11's vital signs were documented, with a 9/10 left back pain on the numeric pain assessment scale. At 7:03 PM, an order was placed for "Acetaminophen (TYLENOL) tablet 975 mg." At 11:40 PM, P11's ED disposition was set to AMA (Against Medical Advice). There was no documentation that the medication was administered or refused by P11. P11's medical record lacked evidence that his/her pain was treated or reassessed during the four (4) hours and 49 minutes that P11 was in the ED. On 10/10/24 at 2:00 PM, S13 confirmed these findings.




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