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Based on record review and interview, the facility failed to ensure the patient's rights were upheld by not ensuring the patient received consistent pain management assessments or an effective pain management plan prior to discharge in one of one chart reviewed. (Patient ID# 1)

Findings included:

HHSC Complaint intake received via telephone hotline by Patient ID #1 on 8/20/2021 stated on 8/16/2021 "patient was not given medication for 4 hours. She was discharged from the hospital. There was no notice. Patient is still ill and in pain. She did not have enough time to recover from sickle cell crisis and is in need of further hospital treatment."

Medical record review of patient's (ID#1) medical record on 3/21/2023, documentation revealed:
8/13/2021 - Admission H&P. Provider Staff ID # 67 failed to document pain as a component of physical exam. However, patient's diagnoses are sickle cell crisis and chest pain.
8/16/2021 - Provider staff ID #68 documented "subjective - patient still complaining of significant pain. States symptoms has not improved over past 24 hours ..." Physical exam failed to reflect pain assessment. Assessment and plan reflected adding oral tramadol and norco as needed.
8/18/2021 - Discharge Summary stated pain was well controlled with oral regimen. There was no pain assessment noted in physical exam. The nursing notes reflected:
8/15/2021 08:38 am DVPRS (Defense and Veterans Pain Rating Scale) Pain scale - 9
8/15/2021 8:23 pm DVPRS Pain scale - 8
8/16/2021 09:17 am DVPRS Pain scale - 10
8/16/2021 8:25 pm DVPRS Pain Scale - 9
8/17/2021 09:04 am DVPRS Pain scale - 9
8/17/2021 8:07 pm DVPRS Pain Scale - 10
8/18/2021 8:53 am DVPRS Pain Scale - 9
There was no documented communication with the provider of patient's pain assessments and refusal of oral pain medication.

Record review of facility's patient rights forms stated "Patients Rights ....You have the right to have your pain appropriately assessed and managed ..."

Record review of facility's "Pain Assessment and Management Policy" , last reviewed 10/3/2022, stated " Patients have the right to have their pain assessed and appropriately managed. Effective pain management is an integral component of patient care and is an important indicator of quality care. Optimal pain management can diminish suffering, while minimizing complications and side effects of pharmacological agents used." The policy stated "Healthcare providers will encourage the reporting of pain and continue to reassess pain .... Healthcare providers must document all pain assessments and interventions in the electronic medical record." It further stated the "Defense and Veterans Pain Rating Scale (DVPRS) is a functional pain scale designed to be used with patients able to self-report."

Interview with quality personnel (ID# 51) on 03/21/2023 at 245 pm, she confirmed the facility's patients rights policy included the right to pain management assessment and management. She validated the facility's pain assessment and management policy stated that the pain scale should be documented prior to administering the appropriate ordered medication. In addition, "uncontrolled pain should be communicated and documented with the physician/advanced practice provider."