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Based on interview, and record review, the facility failed to ensure the facility's policy and procedure (P&P) for pain management was implemented, for four of 30 sample patients (Patients 4, 9, 14, and 15), when:

1. For Patient 4, pain medication was not administered for two and a half hours when the pain score (numerical pain tool where mild pain is scored 1-3, moderate pain is scored 4-6, and severe pain is scored 7-10) was 10;

2. For Patient 9, pain score was 9, and pain medication was not administered;

3. For Patient 14, pain score was not assessed and documented; and

4. For Patient 15, pain score was not documented prior to discharge.

This failure had the potential to impact the health and treatment of the patients, and cause delays in patient care.

Findings:

1. On October 29, 2024, at 2 p.m., Patient 4's medical record was reviewed with the Chief Quality Officer (CQO).

The facility document titled, "Emergency Department Record," dated October 3, 2023, indicated Patient 4 presented to the Emergency Department (ED) for evaluation of abdominal pain.

The facility document titled, "Vital Sign Report," indicated, "...10/03/2023 17:41 [October 3, 2023, at 5:41 p.m.] ...Pain Score: 10...10/03/2023 18:16 [October 3, 2023, at 6:16 p.m.] ...Pain Score: 10...10/03/2023 20:12 [October 3, 2023, at 8:12 p.m.] ...Pain Score 10..."

The facility document titled, "Medication Administration Record," indicated, Patient 4 was administered "...Fentanyl Citrate [a medication used for pain management]...50 mcg/1ml [micrograms per one milliliter, unit of measurement] ...10/03/23 20:12 [October 3, 2023, at 8:12 p.m.].

An interview was conducted with the CQO on October 29, 2024, at 2:15 p.m. The CQO stated Patient 4 should have received medication for pain management sooner than two and half hours.

2. On October 29, 2024, at 3:20 p.m., Patient 9's medical record was reviewed with the CQO.

The facility document titled, "Emergency Department Record," dated October 6, 2023, indicated Patient 9 presented to the ED with difficulty breathing, abdominal distention (swelling), and had a history of cirrhosis (a condition that occurs when the liver becomes damaged, making it difficult to function properly) of liver.

The facility document titled, "Triage [sorting of patients according to the urgency of their need for care] Report," dated October 6, 2023, at 9:20 p.m. indicated, "...Pain Assessment [evaluation]...9..."

An interview was conducted with the CQO on October 29, 2024, at 3:30 p.m. The CQO stated there was no documentation Patient 9's pain was addressed, and no pain medication was administered to alleviate Patient 9's pain.

3. On October 30, 2024, at 11 a.m., Patient 14's medical record was reviewed with the CQO.

The facility document titled, "Emergency Department Record," dated October 25, 2023, indicated Patient 14 presented to the ED on a 5150 hold (allows the involuntary psychiatric hold of individuals considered a danger) after assaulting his mother.

The facility document titled, "Triage Report," dated October 25, 2023, at 10:59 p.m., indicated Patient 14's pain assessment was not documented.

The facility document titled, "Vital Sign Report," dated October 25, 2023, through October 30, 2023, indicated Patient 14's pain assessment was not documented.

An interview was conducted with the CQO on October 30, 2024, at 11:10 a.m. The CQO stated Patient 14's pain assessment should have been documented and this was not done.

4. On October 30, 2024, at 11:15 a.m., Patient 15's medical record was reviewed with the CQO.

The facility document titled, "Emergency Department Record," dated October 30, 2023, indicated Patient 15 presented to the ED with abdominal pain and nausea.

The facility document titled, "Triage Report," dated October 30, 2023, at 12:23 p.m., indicated, "...Pain Assessment...10..."

The facility document titled, "Medication Administration Record," indicated Patient 15 was administered "...Morphine [a medication used for pain management]...4 mg/1ml [milligrams per one milliliter, unit of measurement]...10/30/23 14:19 [October 30, 2023, at 2:19 p.m.]..."

The facility document titled, "Vital Sign Report" dated October 30, 2023, through October 31, 2023, indicated Patient 15's "...Pain Score...8...10/30/2023 14:19 [October 30, 2023 at 2:19 p.m.]..."

An interview was conducted with the CQO on October 30, 2024, at 11:25 a.m. The CQO stated there were no additional pain assessments documented for Patient 15, and a reassessment of pain should have been completed prior to Patient 15's discharge and this was not done.

A review of the facility P&P titled, "[Name of Facility] Pain Management," dated November 2021, was conducted and indicated, "...Patients seen in the Emergency Department [ED] shall receive a screen during the triage or initial assessment process to identify the presence of pain... If acute pain issues were identified, then the patient should be reassessed at least at time of discharge or transfer...When provided, treatment shall be consistent with the patient's clinical presentation and objective findings. The treatment modality selected shall be appropriate for the patient's needs. Treatment is to be provided in a timely manner...If a treatment intervention for pain is provided, then the response to that intervention must be assessed. Reassessment is recommended to occur within 15 -60 minutes following treatment (depending on the type of intervention). However, by policy, this reassessment must occur at least at the time of discharge or transfer..."