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Based on medical record, and facility policy and procedure review, staff interview, the facility failed to ensure a pain assessment and/or pain management was documented. This affected one ( Patient #3) of eleven patients whose medical records were reviewed. The facility active census at the time of the survey was forty one.

Findings: The medical record review for Patient #3 was completed on 12/19/13 at 11:30 AM. The patient had been seen by the primary care physician on 11/06/13 for symptoms of unrelieved chest pain. The patient had a diagnosis of precordial pain, hyperlipidemia, and a thirty year history of smoking . The patient's primary physician had referred the patient to the hospital for an outpatient electrocardiogram stress test on 11/06/13.
The physician's progress note in outpatient services on 11/06/13 revealed that during the cardiac stress test the patient experienced chest pain and shortness of breath. The cardiac stress test was stopped after three minutes and forty-six seconds due to these symptoms. The medical record did not contain documentation of the assessment of the patient's chest pain before, during, or after the cardiac stress test. The patient was discharged from the outpatient facility on 11/06/13 at 1:15 PM and advised to follow up with the referring primary care physician.

An interview, conducted on 12/18/13, at 2:30 PM, with Staff C and Staff D revealed many patients experience chest pain during a stress test but the pain is not necessarily related to a myocardial infarct (heart attack).
Staff C and D said they would expect a patient experiencing chest pain would receive nitroglycerine (a medication prescribed for chest pain).

Review of the facility policy PC-GMH/SOIN PAIN MANAGEMENT with an effective date of 06/07/13 was completed on 12/19/13 at 10:32 AM. The policy applied to both inpatient and outpatient services. The policy indicated a comprehensive pain assessment is to be completed according to department policy. Pain management will be considered as an element of the plan of care for all patients. This includes re-evaluation that includes pain at rest, pain with activity, pain quality, and site/location.

The medical record documented Patient #3 returned to the facility's emergency department on 11/07/13 at 12:55 PM, with complaints of significantly worsened chest pain.
The patient was evaluated, treated, and admitted to the facility by the emergency room physician.
Patient #3 was transferred to an affiliate facility on 11/08/13. A cardiac catheterization was completed on 11/08/13 at 3:20 PM. A right coronary angiogram was performed with stents being placed. The conclusion indicated severe coronary artery disease of the right coronary artery. A successful intervention was completed and the patient was admitted to the facility for post percutaneous coronary intervention care.