HospitalInspections.org

Based on staff interviews, medical record reviews and reviews of facility policy and procedures, the facility failed document assessment/reassessment of pain for approximately five (5) hours while Patient #1 was receiving tests in preparation for surgery on one (1) out of three (3) medical records reviewed, Patient #1.

Findings Include:

An interview with the Administrator on 10/14/2024 at 5:31 p.m., confirmed the medical record has no documentation of pain assessments after 6:42 p.m. and that Patient #1 should have been assessed/reassessed for pain and received treatment while in the Emergency Department. The Administrator also confirmed the facility's only policy on pain management is for "Patient Controlled Analgesic (PCA) Pumps".

Review of Patient #1's medical record titled "Pain Assessment flow sheet," revealed that the patient had a pain assessment on 04/05/2024 at 6:40 p.m. and 6:42 p.m. and no further pain assessment or reassessment was documented in the medical record until 4:30 a.m. after surgery was completed.

Review of the patient's medical record titled "Patient Care Timeline," revealed the provider ordered Zofran 4 milligram (mg) injection and Morphine 2 mg injection at 12:04 a.m. Review of the timeline revealed there was no pain scale assessment or pain reassessment documented during this time frame.

Review of facility submitted documentation revealed the facility's Pain Management Policy only addressed the use of PCA pumps.

Exit conference held 10/14/2024 at 6:05 p.m. with Administrator, Chief Nursing Officer and Patient Advocate to discuss survey findings with no further information submitted.