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Based on interviews, observation and policy review, the facility failed to comply with 489.24 by failure to ensure there were no deterrents from seeking medical care for pain in the Emergency Department in the form of posted information sheets regarding management of prescription narcotics. (A 2402) The cumulative effect of this systemic practice resulted in the facility's inability to ensure that all patients pain needs would be met. The average daily census of the Emergency Department is 300 patients.

Based on observations, policy review and interviews, the facility failed to ensure all Emergency Department patients were not deterred from seeking medical care in the Emergency Department as a result of viewing the posted information sheet regarding management of prescription narcotics. The average daily census of the Emergency Department is 300 patients.

Findings included:

1) A tour of the hospital's Emergency Department (ED) was conducted on 01/27/14 beginning at 10:51 AM with Staff B and C. Upon entering the designated West Emergency Department, a 8.5" by 11" sheet of paper in a clear plastic sleeve was observed hanging on a wall adjacent to the nurses station at eye level immediately outside of the patient bays. The paper contained language entitled "In the Interest of properly managing the prescribing of narcotics, The MetroHealth System Department of Emergency Medicine has adopted the following policies." Verbatim the policy read as follows:

1. The Emergency Department (ED) will not refill narcotic prescriptions for patients who have lost prescriptions or have had medications stolen. These individuals will need to contact their primary care physician for their prescription refills.

2. The ED will not refill narcotic prescriptions for patients with chronic pain or a worsening of chronic painful conditions when those patients are under active treatment by a primary care doctor, PM & R, pain management or surgical clinics or patients who have received narcotic prescriptions within the last 3 months as shown by the medical record review or review of the Ohio pharmacy website. These individuals will be referred back to their primary care doctor for appropriate pain management.

3. After a medical screening exam, emergency physicians may determine that emergency pain management may be required for a patient with chronic pain and will treat appropriately.

4. If the patient's primary care or specialty physicians have made a decision that the patient's condition should not be managed with narcotics, the ED will follow those recommendations absent a new development.

5. The ED may refer patients who attempt to obtain narcotics by deception to law enforcement.

6. The ED may identify patients who require a care plan for management of their chronic pain. This will be recorded their medical record.


Staff B and Staff C were both shown the paper at the time of the observation and then asked to obtain a photocopy of it. Depending on the patient's chief complaint, the patient would sign in, receive triage, and then be excorted back to the ED and then to a particular bay for examination. This is the point at which the posting may have been viewed by the patient, once within the ED and on the way to the bay for examination. The posting was not in the patient rooms or lobby/waiting area.


2) Staff A stated in interview on 01/27/14 at approximately 4:15 PM that all of those posted information sheets were supposed to have been taken down and one of them must have been missed. Staff A was informed that several of these sheets had also been observed throughout the ED, placed within clear plastic sleeves and tacked to the walls in view of staff, patients, and visitors.

3) Staff B was then interviewed regarding the posting on 01/28/14 beginning at 3:20 PM. Staff B was shown the paper and asked how it came to be posted in the ED. Staff B stated the posting was originally a "hard" sign made of fiberglass or similar material. Staff B stated the signs were posted around the triage area and throughout the Emergency Department. Staff B stated the department found out they were not allowed to be posted about six months ago and so they were removed. Staff B stated he/she did not know where the paper posting had come from but would attempt to find out.

4) Staff E was then interviewed on 01/29/14 beginning at 10:41 AM. Per Staff E, he/she developed the "policy." Staff E stated the policy came about after collaborating with the state pharmacy board in an attempt to address narcotic pain management in the ED. Staff E stated the policy was modeled after that of the Veteran's Administration. A draft of the policy was then sent to the state board of pharmacy for review and it was reportedly accepted. The same policy was circulated amongst the hospital's Emergency Department physicians and the medical executive committee for review. The final version of the policy was then posted in the ED.

Staff E continued, stating that a ruling by Region 4 of CMS (Centers for Medicare and Medicaid) sometime in the summer of 2013 then led to the posted versions of the policy being taken down from within the ED.

5) On 1/28/14 at 8:43 AM, the facility's Patient Bill of Rights and Responsibilities policy (policy III-15) was reviewed. The policy stated you have the right to receive information about pain and pain relief measures from a committed staff of health care providers. Health care providers will respond to your reports of pain and provide pain management therapies as appropriate.

On 1/29/14 at 11:35 AM, Staff M provided a copy of facility communications regarding the removal of pain signs in the emergency department from 1/20/14. The communications stated the facility had taken down the signs.

On 1/29/14 at 1:31 PM, the facility's Pain Management Program policy was reviewed. The patient is the best judge of the intensity, relief and the level that they consider to be tolerable, therefore, the management of pain is a patient's right and requires interdisciplinary involvement to optimize effective treatment. The policy stated a thorough assessment is to be completed and documented when pain is reported.