HospitalInspections.org

Based on hospital policy review, closed medical record review and staff interviews, the hospital's outpatient clinic nursing staff failed to assess a patient's pain for 2 of 5 patients who had a procedure at Clinic A (Patient # 4 and # 11).

The findings included:

Review on 11/13/2018 of a policy titled "Pain Management Policy" effective date 04/26/2017 revealed "...Pain is a universal experience for all human beings. Unmanaged pain can be harmful and expensive, often decreasing the patient's ability to care for themselves and delaying recovery. The most reliable measure of the intensity and quality of pain is the patient's self-report. For those patients who cannot communicate the intensity of their pain and who have a condition or undergone a procedure that is known to elicit pain, then the nurse must assume pain is present...and use the appropriate pain scale for the identification of pain...The management of pain requires assessment, reassessment...A. Initial Assessment: 1. All patients will be screened for presence/absence of pain. a. At the time of admission or presentation for care...b. With any new complaint of pain by patient/family or caregiver..."

1. Closed medical record review of Patient #4 revealed she presented to Clinic A on 06/20/2018 for a uterine aspiration procedure (dilation of cervix and removal of pregnancy tissue). Review revealed Patient #4 arrived to Clinic A at 0917 and vital signs were assessed at 0936, during the intake assessment. Review of the physician's history and physical revealed "(Patient #4)...for treatment of missed abortion at 12 weeks 1 day gestation...Missed Abortion: Requests to proceed with surgical management. See procedure note..." Review revealed Patient #4 was consented and completed a uterine aspiration procedure. Review of RN #1's (Registered Nurse) notes revealed "Frequently monitored patient during procedure which included multiple sets of vital signs and provided emotional support throughout the entire process..." Review revealed Patient #4 had two more sets of vital signs at 1125 and 1145. Review of the nursing note revealed "...Reviewed post operative care and precautions with patient..." Patient #4 was discharged at 1150. Review failed to reveal pain assessments for Patient #4 before, during, or after her procedure.

Interview on 11/15/2018 at 0920 with RN #1 revealed patients were assessed for pain when they first arrived to the clinic, during the intake assessment. Interview revealed if patients were not having pain RN #1 did not document a pain assessment. Interview revealed if patients had pain during the uterine aspiration procedure RN #1 would hold their hand, deep breathe with them, or rub their belly. Interview confirmed Patient #4 did not have any pain assessments while at Clinic A.

Interview on 11/14/2018 at 1308 with Clinical Operations Director #1 revealed the expectation for pain assessments were patients were assessed for pain at initial contact with the clinic, before the procedure and after the procedure. Interview revealed Patient #4 did not have any pain assessments documented in her medical record.

2. Closed medical record review of Patient #11 revealed she presented to Clinic A on 11/09/2018 for a uterine aspiration procedure. Review revealed Patient #11 arrived to the clinic and vital signs were assessed at 1232, during the intake assessment. Review of the physician's history and physical revealed "(Patient #11) presents today after failed medical management of MAB (missed abortion)...After the discussion of the risks, benefits, and indications of each options she has elected to proceed with surgical management..." Review revealed a uterine aspiration was performed on Patient #11. Review of RN #1's notes revealed "Frequently monitored patient during procedure which included multiple sets of vital signs and provided emotional support throughout the entire process..." Review revealed Patient #11 had two more sets of vital signs at 1440 and 1500. Review of RN #1's note revealed "Reviewed post operative care and precautions with patient..." Patient #11 was discharged at 1500. Review failed to reveal pain assessments for Patient #11 before, during, or after her procedure.

Interview on 11/15/2018 at 0920 with RN #1 revealed patients were assessed for pain when they first arrived to the clinic, during the intake assessment. Interview revealed if patients were not having pain RN #1 did not document a pain assessment. Interview revealed if patients had pain during the uterine aspiration procedure RN #1 would hold their hand, deep breathe with them, or rub their belly.

Interview on 11/14/2018 at 1308 with Clinical Operations Director #1 revealed the expectation for pain assessments were patients were assessed for pain at initial contact with the clinic, before the procedure and after the procedure. Interview revealed Patient #11 did not have pain assessments documented in her medical record.

NC00142112, NC00142873