HospitalInspections.org

Based on record review and interview on 04/14/2021 of the emergency department (ED) records of five patients who presented to the ED with abdominal pain revealed the nursing staff facility failed to address the pain level in 5 out of 7 patients (ID #1,5,7,9,11) in triage.

Findings Included:

Five of seven (ID#1,5,7,9,10) patients presented to the ED with a complaint of abdominal pain. The pain level was not documented during the first encounter or triage. The patient's pain level was documented many hours later.

Record review of the facility policy "Pain Assessment and Reassessment", dated 08/19/2019 stated, H. Pain reassessment and documentation shall occur with each new report of pain.

Record review of patient triage records revealed the following:

Patient (ID#1) was triaged on 09/02/2020 at 1751 for abdominal pain, no documentation of the pain level was completed. On 09/02/2020 @ 2151 Patient (ID#1) had a pain level of 6 and received Morphine 4 mg, IVP.

Patient (ID#5) was triaged on 04/14/2021 at 1803, no documentation of the pain level was completed. On 04/14//2021 at 2036 her pain level was documented to be 10/10.

Patient (ID#7) was triaged on 04/14/2021 at 0715 with abdominal pain, no documentation of the pain level was completed. On 04/14/2021, at 1000, her pain level was documented to be 8/10.

Patient (ID#9) was triaged on 04/14/2021 at 1554 with abdominal pain, no documentation of the pain level was completed. On 04/14/2021, at 2030, his pain level was documented to be 8/10.

Patient (ID#11) was triaged on 04/14/2021 at 1300 with abdominal pain, no documentation of the pain level was completed. On 04/14/2021, at 0043, her pain level was documented to be 7/10. She was medicated with Morphine 4 mg IVP at 0043.

Interview on 04/14/2021 at 1100 with staff RN (ID#72) stated, pain level should be assessed once a patient is in the room, and assessed upon arrival and every four hours and a minimum of every shift.

Interview on 04/14/2021 at 1133 with ED Director (ID#73) who stated "they (the nurses) are assessing pain and not documenting in the record".