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Based on record review and interview, the facility failed to ensure a patients pain was assessed after administering a medication for pain management for one (Patient #4) of 22 patients.

Findings:

Patient #4

A review of an emergency medicine department clinical record dated 08/19/23 showed the patient presented to the emergency medicine department for complaints of right leg pain. The medical screening examination showed a diagnosis of claudication of the right lower extremity. Documentation showed Oxycodone 10 milligrams with 325 milligrams of acetaminophen tablet (an opiod pain medication) was ordered for pain at 2:56 p.m. and administered at 3:00 p.m. Documentation showed a nursing assessment of the patient's pain at 1:54 p.m. as pain in the leg. Documentation did not identify the type, level or specific anatomical location of the patients pain before or after the pain medication was administered. Additional documentation showed the patient was discharged from the emergency medicine department to home at 3:14 p.m.

On 07/30/24 at 10:30 a.m., Staff #A stated no nursing assessment of pain was documented before or after the pain medication was administered.