HospitalInspections.org

Based on policy review, medical record review, and interview, the facility failed to ensure that the nursing service met patient needs related to pain management for 1 of 3 (Patient #5) sampled patients.

The findings included:

1. Review of the hospitals "Patient Rights and Responsibilities," policy dated 11/17/2014, revealed " ...Each patient is considered a partner in healthcare...encourages respect for the personal preferences ad values of each individual ...Patients have the right to ...Personal privacy, privacy of their health information and to receive a notice of the facility's privacy practices ...Pain management ...Care or services provided without discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression ...Be free from neglect, exploitation, and verbal, mental, physical, and sexual abuse ...An environment that is safe, preserves dignity and contributes to a positive self-image ..."

Review of the hospital's "Pain Management Program Policy," policy dated 10/10/2020, revealed " ...The patient's self-report of pain is accepted as the most reliable marker of the presence and extent of pain ...Pain will be assessed on initial assessment, an ongoing reassessment of pain is performed on a regular basis utilizing appropriate, reliable, and valid pain assessment tool ...Patient-specific pain management outcomes will be established and I if not achieved will elicit a review and modification of the pain management program ..."

2. Review of the medical record revealed Patient #5 was admitted to the hospital on 6/7/2023 with a diagnosis of Cholecystitis.

Review of the Triage Note dated 6/7/2023 at 8:17 PM, revealed, "...Chief Complaint: pt [patient] having bilateral flank pain also mid abdominal pain and feel nauseous pt is also constipated been going on for days ...[heart rate...85]...[blood pressure...125/77]...alert...oriented x 4 [patient understands who they are, where they are, approximate date or part of the day, and what is happening]...Pain Present: Yes actual or suspected pain...Pain location: Abdomen upper, flank...Laterally: Bilateral...Quality: Sharp, tenderness ...Time Pattern: Constant...Numeric Rating at Rest: 10 = Worst possible pain..." There was no documentation the triage nurse notified the medical provider that Patient #5 reported severe abdominal pain.

Review of the History of Present Illness Note [Physician Assistant Note] dated 6/8/2023 at 12:46 AM, revealed Patient #5 was a 35-year-old female who presented to the emergency department (ED), "...for nausea and vomiting. Patient reports she was sent over here by her gastroenterologist for a work-up given the amount of pain she is in...Denies any shortness of breath or chest pain. Reports she is having stabbing abdominal pain..."

Review of the History and Physical dated 6/8/2023, revealed, "...History of present illness: Patient is a 35-year-old African-American female that comes into the emergency room complaining of severe epigastric abdominal pain. She reports nausea and vomiting. She also reports that she has been having episodes of constipation. Patient states that her pain has been ongoing for approximately 2 weeks however it seems to have worsened over time. Patient reports that roughly a year ago she had similar symptoms. At that time she was told that her gallbladder was dysfunctional and may need to be removed. However she never had surgery. Patient was not noted to have elevated LFTs [liver enzymes]. Additionally she was not noted to have elevated white blood cell count. Ultrasound of the right upper quadrant was concerning for gallstones. She has had a laparoscopic Roux-en-Y bypass [surgery through small incisions in the abdomen for the purpose of weight loss] in the past. She does report that symptoms seem to be worse with eating..."

Review of the Radiology Results dated 6/8/2023, revealed, "...Gallbladder distention with some internal sludge but no gallstones. No gallbladder wall thickening or pericholecystic fluid is seen. Clinical correlation for signs or symptoms of acalculous cholecystitis still recommended..."

Review of the Medication Administration Record revealed Patient #5 received Fentanyl [narcotic] on 6/8/2023 at 12:53 AM. There were no other documented interventions or medications given to address Patient #5's pain documented from the time that Patient #5 first reported pain at a level of 10 (worst possible pain) on 6/7/2023 at 8:17 PM until Patient #5 received Fentanyl on 6/8/2023 at 12:53 AM (4 hours 36 minutes).

Review of the Surgical Documentation revealed Patient #5 was admitted to the hospital and underwent a laparoscopic cholecystectomy (surgical removal of the gall bladder through small incisions in the abdomen) for a distended gall bladder on 6/8/2023.

3. During an interview on 11/2/2023 at 1:10 PM, the Interim Emergency Room Director stated, "...Patient was admitted on 6/7/2023 at 8:02 PM; Triaged on 6/7/2023 at 8:17 PM; seen by a provider on 6/8/2023 at 12:46 AM; meds [medications were ordered] at 12:50 AM and given at 12:53 AM..." When asked why the patient was allowed to remain in pain (from 6/7/2023 at 8:17 PM to 6/8/2023 at 12:53 AM, the Interim Emergency Room Director stated, "...The expectation is if a patient comes in with that pain level, the nurse is to notify the provider..." The Interim Emergency Room Director confirmed there was no documentation that the nurse notified the provider of Patient #5's reported pain level of 10 (worst possible pain).

During an interview on 11/20/2023 at 10:45 AM, the ED Technician [Tech] stated, "...when someone enters the ED, they come to the window and give us their ID [identification such as a driver's license], and basic information is put into the computer at that time. We try and ask some basic questions about their complaint to determine if they are emergent or not...I print out a face sheet and wrist band for the patient and place them in the waiting room...a paramedic or tech will monitor the waiting room...get vital signs, and any additional complaints a patient might have...will assist in getting the patient's labs or diagnostic tests after the triage nurse has ordered them...there are nursing protocols for the triage nurse..."

During an interview on 11/20/2023 at 11:50 AM, Registered Nurse (RN) #1 confirmed she was an RN in the ED and had worked in the triage nursing role. RN #1 confirmed the triage nurse should report to the medical provider if a patient reported severe pain during the triage assessment.

During an interview on 11/20/2023 at 11:58, RN #2 confirmed he was an RN in the ED and had worked in the triage nursing role. RN #2 confirmed the triage nurse should report to the medical provider if a patient reported severe pain during the triage assessment.

During an interview dated 11/20/2023 at 1:05 PM, the Physician's Assistant (PA) stated, "...Sometimes the patient says they have 10/10 pain, but after reviewing their blood pressure and heart rate and talking with the patient, they are really alright...I wasn't even in the building at 8:00 PM...I arrived to the ED around 9:00 PM...I addressed the pain as fast as I could...There were other clinicians in the ED seeing other patients, and I'm sure they were probably more emergent than she [Patient #5] was at that time..." When asked if he was familiar with the hospital's pain policy the PA stated, " ...No, but I am familiar with how to deal with a patient's pain..."