HospitalInspections.org

Based on record review and interview, staff failed to perform pain assessment/reassessment, interventions or focused assessment in 4 of 10 medical records reviewed [Patient #4,5,6,&7], in a total of 10 medical records reviewed.

Review of the facility's policy 3-1616 "Pain Management Policy," dated 09/25/2024 revealed: " ...Upon patients entry into the [Facility} Ambulatory, Outpatient, Emergency and inpatient departments, the patients will have pain screened as a part of ongoing patient care and assessment expectations during qualifying RN level visits, Provider level visits or admissions. Information gathered during patients' encounter may indicate the need for a more comprehensive assessment. A reassessment may occur depending on the course of the visit ...If the patient responds that they do not have pain, the screening is finished and results documented in the EHR. If the patient responds that they have pain, they will be asked to state their level of pain, if able, using one of the appropriate pain screening/assessment tools ...Support staff will take part in the collection which include but are not limited to; pain site, description of pain, frequency of pain, physiological and/or psychological effects of pain, ... and interventions attempted to alleviate pain. Results will be documented in the EHR (Electronic Health Record) and communicated to the provider/RN for the pain assessment process to be conducted."

Review of the facility's policy 3-2854 "Standards of Nursing Practice Policy-Emergency/Urgent Care Department," dated 11/09/2022 revealed: " ...The RN will initiate accurate and ongoing assessments of physical and psychosocial components of the patient, utilizing a systematic approach. This is done timely and ongoing for duration of care ...The RN will assure vital signs are with-in normal limits or acceptable by provider for discharge/admission."

Patient #4 was a 29-year-old patient admitted to the ED on 02/07/2025 at 10:19 AM with abdominal pain. Patient #4 rated pain an 8 upon admission. No pain reassessment or pain interventions documented. Patient #4 was evaluated by provider with normal test results. Patient #4 given discharge instructions to follow up with her primary care provider. Discharged home on 02/07/2025 at 1:36 PM.

Patient #5 was a 16-year-old patient admitted to the ED on 02/07/2025 at 10:23 AM with right lower quadrant abdominal pain. No pain assessment was completed on Patient #5 in triage. No focused assessment of gastrointestinal system documented by RN. Patient #5 was evaluated by physician and was admitted to the hospital with acute appendicitis. Patient discharged from the ED and admitted at 6:57 PM.

Patient #6 was a 24-year-old patient admitted to the ED on 03/07/2025 at 11:33 AM after being physically assaulted and strangled. Patient #6 came in with a pain assessment of 10/10 in her left wrist. Patient #6 had no pain reassessments or pain interventions documented. Patient #6 was evaluated for injuries sustained, given a wrist brace, and given discharge instructions. Patient #6 was discharged home on 03/07/2025 at 2:01 PM.

Patient #7 was a 25-year-old female admitted to the ED on 03/25/2025 at 10:30 AM with left lower quadrant abdominal pain and urinary urgency. No pain assessment or focal assessment on urinary system were completed by nursing on admission. Ultrasound and CT scan revealed ovarian cyst. Patient #7 received IV Ketorolac (Pain medication) on 03/25/2025 at 1:44 PM. No pain reassessment completed. Patient treated and discharged from the ED on 03/25/2025 at 4:49 PM.

During an interview on 03/26/2025 at 09:25 AM ED Supervisors F and G stated that every patient should have pain assessed during their ED triage. If pain is present in triage a comprehensive pain assessment should be completed during the ED assessment. Both ED Supervisors F and G also stated that they would expect a nurse to conduct a focused assessment on the patient's chief complaint.