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Based on review of medical records, facility policy and procedures, and staff interview, it was determined the facility failed to ensure nursing staff evaluated the care for each patient on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy. The nurse staff failed to assess the pain level for five (#1, #2, #3, #4, #10) of ten medical records sampled.

Findings included:

A review of the policy entitled, "Care of Adult Patient With Chest Pain," #BC-CS-904, revised 06/19, showed that with episodes of chest pain or discomfort, the nurse should assess the patient for:
- Time of onset, location, radiation, duration, intensity, and quality
- Response to interventions.

A review of the policy entitled, "Assessment/ Reassessment of (Adult) Patient," #NCL0132, revised 02/2019, showed:
- The time frame for the initial assessment and reassessment is defined by department / discipline policy ...
- The scope of assessments and reassessments are based on the patient's diagnosis and care setting ...
- The patient's status is reassessed at regular intervals ...
- Patient initial assessment in the Emergency Department (ED) initiated and documented within 15 minutes of arrival ...
- Scope of the initial assessment should focus on the chief complaint and every 2 hours and as needed for intervention and treatment.

A review of the policy entitled, "Documentation: Nursing," #NCL0008, revised 05/19, showed nursing should document in the medical record, with routine assessment and as needed, using the appropriate pain scale. If pain is not present, document zero.

A review of Patient #1's ED physician documentation note dated 03/28/19, showed the patient arrived at 5:40 AM via emergency medical services (EMS) for complaints of chest pain(CP).

A comprehensive review of Patient #1's nursing pain assessment and reassessment documentation, failed to show the presence of an assessment for pain upon arrival to the ED. The first documented pain level taken was at 6:30 AM.

A review of Patient #2's ED physician documentation note dated 03/28/19, showed the patient arrived at the ED with complaints of CP at 5:36 PM.

A comprehensive review of Patient #2's nursing pain assessment and reassessment documentation, failed to show the presence of an assessment for pain upon arrival to the ED. The first documented pain level taken was at 6:53 PM and the patient rated his CP a 4 on scale of 0-10, 10 being the highest.

A review of Patient #3's ED physician documentation note dated 03/28/19, showed the patient arrived at the ED via EMS, with complaints of shortness of breath, difficulty breathing and having respiratory distress at 2:16 AM. The patient was taken to the Cardiac Catheterization Laboratory at 1:31 PM for a heart catheterization and possible coronary intervention.

A comprehensive review of Patient #3's nursing pain assessment and reassessment documentation, showed that on 03/28/19 from 2:16 AM to 1:31 PM, nursing performed a pain assessment at 2:16 AM and no further pain assessments were documented in the ED medical record.

A review of Patient #4's ED physician documentation note dated 11/19/19, showed the patient arrived at 10:07 AM for complaints of chest pain (CP) and nausea.

A review of Patient #4's nursing pain assessment documentation, showed the fist pain assessment was performed at 10:20 AM and the patient rated the CP a 6 on scale of 0-10, 10 being the highest. A comprehensive review of Patient #4's nursing pain assessment and reassessment documentation, failed to show presence of a reassessment for pain. Patient #4 was discharged from the facility at 12:10 PM on 11/19/19.

A review of Patient #10's ED physician documentation note dated 10/31/19, showed the patient arrived at 1:13 PM via EMS, from the transfusion center, for complaints of rash, hives and CP.

A compressive review of Patient #10's nursing pain assessment documentation failed to show nursing performed an initial pain assessment. The first pain assessment documented was at 4:30 PM, 3 hours 17 minutes after arrival to the ED with complaints of CP.

On 11/20/19 at 2:00 PM, an interview with the ED assistant nurse manager, confirmed the above ED medical record findings.