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2401 WEST BELVEDERE AVENUE

BALTIMORE, MD 21215

CONTENT OF RECORD

Tag No.: A0449

Based on the review of 5 open and 8 closed records, the hospital failed to assess patient #7's pain, and failed to reassess patient #4 and #11's pain after receiving pain medication.

Patient #7 presented to the hospital 07/10/2016 for being pepper sprayed in the eyes by police. No pain score assessment was done during the Emergency Room visit.
Patient #4 presented to the hospital 07/07/2016 for pain in back and weakness. Morphine was given on 07/07/2016 at 1356 with no pain score. A sedation score of 1-Awake and alert was completed. No pain score was reassessed an hour after the pain medication was given to verify effectiveness. Per the pain management policy pain should be reassessed within one hour of an intervention.
Patient #11 presented to the hospital 08/24/2016 for chest pain. Nitroglycerin was given 08/24/2016 at 0442 for a pain score of 9 and 0450. No pain reassessment was done an hour after to determine the effectiveness of the medication.