HospitalInspections.org

Based on policy review, medical record review and interview, the hospital failed to ensure all licensed nurses followed the policies and procedures of the hospital regarding assessing patients for pain and reassessing the patients' response to interventions for pain for 3 of 21 (Patient #1, 5 and 7) sampled patients who presented to the Emergency Department (ED) with complaints of pain.

The findings included:

1. Review of the hospital "[named Hospital] Medical Screening Examination and Stabilization Policy" last revised 09/2022, revealed, "Purpose: To establish guidelines for providing appropriate medical screening examinations (MSE)...The MSE must be appropriate to the individual's presenting signs and symptoms and the capability and capacity of the hospital. c. An on-going process. The individual shall be continuously monitored according to the individual's needs until it is determined whether or not the individual has an EMC, and is he or she does, until he or she is stabilized and appropriately admitted or transferred...7. Stabilizing Treatment Within Hospital Capability...b. Stabilizing treatment within the hospital capability and transfer. Once the hospital has provided an appropriate MSE and stabilizing treatment within its capability, an appropriate transfer may be effected..."

Review of hospital policy, "Assessment and Reassessment of the Emergency Department Patient" approved on 04/2019, revealed "...a rapid assessment is the initial assessment performed upon any patient arrival to the Emergency Department ...the rapid assessment include ...pain leve ...a focused nursing assessment evaluates pertinent information related to the patient's chief complaint, condition and symptom ...a focused nursing assessment is required for patients with acuity levels of 1, 2, and 3 following the rapid initial assessment ...a detailed nursing assessment is an assessment to further assess the patient's chronic conditions, health history, and additional screenings for nutrition, substance abuse, and safety/abuse to determine holistic health care needs. A detailed nursing assessment is required for patients with acuity levels of 1, 2, and 3 following the rapid and focused assessment ...Triage Acuity Level 2 patients should have hourly focused reassessments and the ED physicians is notified of all changes in patient status ...Triage Acuity Level 3 patient should have hourly focused assessment and the ED physician notified of any change ...Those who are admitted or transferred will have vital signs and a focused reassessment completed within 30 minutes prior to transfer from the ED...those who are discharged will have vital signs and a focused reassessment completed within 1 hour prior to departure from the ED."

Review of the hospital policy, "Pain Management" approved on 07/2019, revealed " ...Patients have the right to appropriate pain assessment and management...non-pharmacological management of pain will be considered for each patient...staff will be educated regarding pain assessment, treatment, and follow-up..."

2. Medical record review for Patient #1 revealed a 51-year-old male, presented to the hospital's ED via walk in on 02/14/2024 at 11:21 AM with a complaint of swelling to the face and pain.

A triage assessment was initiated at 11:30 AM and revealed the chief complaint "dental pain/injury". The triage nurse documented, "Pt [patient] reports having a teeth cleaning last Thursday, reports after the cleaning began having jaw pain, states starting last night the right side began to swell and the pain worsened..." Patient #1 was assigned a triage acuity level 3. During triage, Patient #1 rated his pain a 9 on a scale from 1-10 with 10 being the most severe pain.

The MSE was initiated at 11:30 AM and revealed, "...he has several teeth that are decayed to the gumline along with large cavities. He is preparing to get dentures. He has had pain in his face since the [dental] cleaning performed last week...the pain is rated as severe...Review of Systems:...ENT [Ear Nose Throat] Several teeth with poor dentition, tender top palpation along the upper molars, there is no obvious drainable abscess, there is swelling noted along the right upper cheek..." The physician ordered Morphine Sulfate (narcotic used for pain management) 4 milligrams via Intravenous [IV] route that was administered at 11:48 AM to treat Patient #1's pain. The physician ordered Ampicillin Sodium [Unasyn, antibiotic] 3 grams IV that was administered at 11:47 AM to address the infection.

A Computed Tomography of the face completed on 02/14/2024 revealed a Right maxillary(upper jaw) lateral incisor periapical dental abscess (a periapical abscess is a pocket of infection [pus] around your tooth root) with cortical dehiscence (the loss of alveolar bone on the front of the tooth) and associated 1.3 X [by] 0.8 X 0.5 centimeter abscess in the overlying soft tissues with moderate associated facial Cellulitis (bacterial infection of the skin-can become red and painful)

After the pain medication (Morphine Sulfate 4 mg IV) was administered at 11:48 AM, a "Dental/ Pain reassessment was documented at 12:57 PM with "No Change". There were no other pain assessments documented by the nurse. At 3:52 PM, a second dose of Morphine Sulfate 4 milligrams IV was administered for pain. At 5:32 PM, Patient #1 rated his pain a 9 out of 10 and at 6:41 PM, Patient #1 rated his pain an 8 out of 10.

Patient #1 was transferred to another hospital on 02/14/2024 at 7:15 PM for oral surgery and dental services not available at Hospital #1, related to his dental abscess and cellulitis

There was no documentation Patient #1's continued pain was communicated to the ED Physician. The nursing staff failed to follow written protocols for pain reassessment. There was no documentation Patient #1 pain was assessed prior to transfer at the time of discharge from Hospital #1. Patient #1 was assigned an acuity level 3, and according to hospital policy, should have had hourly focused assessment with the physician notified of any changes and a focused reassessment within 30 minutes of transfer from the ED.

3. Medical record review for Patient #5 revealed a 35-year-old female who presented to the hospital's ED via walk-in on 04/08/2024 at 10:19 AM with a complaint of dental pain and facial swelling.

A triage assessment was initiated at 11:18 AM and revealed the chief complaint of "Dental Pain/Injury." Patient #5 was assigned a triage acuity level 3. The triage nurse documented, "Pt here with c/o lt [left] sided facial swelling of the lower jaw ..." During triage, Patient #5 rated her pain an 8 on a scale from 1-10 with 10 being the most severe pain.

The MSE was initiated at 10:40 AM and revealed, " ...left lower dental pain and swelling ...reports that she is having some pain with swallowing on the left side..." The physician ordered the following IV (intravenous) medications: Ceftriaxone Sodium (antibiotic) 1 GM (gram) at 10:49 AM, Clindamycin Phosphate (antibiotic) 50 ML (milliliters) at 10:48 AM, lopamidol 100 ML at 12:46 PM and Dexamethasone Sodium Phosphate 10 MG (milligram) at 10:48 AM to address the infection.

A CT of the Neck revealed, "...left mandibular tooth #19 with dental carrie and periapical lucency (favoring periapical abscess) with infectious extension into the subcutaneous soft tissues overlying the left mandible (lower left jaw)..."

Patient #5 was discharged home on 04/08/2024 at 3:30 PM with instructions to follow-up with her dentist or return to the ED if symptoms worsened.

There was no documentation in Patient #5's medical record that pain was assessed or treated after the initial triage assessment at 11:18 AM.

4. Medical record review for Patient #7 revealed a 53-year-old male, who presented to the hospital's ED via ambulance on 02/14/2024 at 8:50 AM with a complaint of chest pain.

A triage assessment was initiated at 8:58 AM and revealed the chief complaint of chest pain. Patient #7 was assigned a Triage acuity level 2. The triage nurse documented, "Pt from home via [ambulance] c/o [complains of] chest pain, sob [shortness of breath], and fluid overload d/t [due to] not having dialysis in a week..." During triage, Patient # 7 rated his pain a 7 on a scale from 1-10 with 10 being the most severe pain.

The MSE was initiated at 9:05 AM and revealed,"...he has not dialyzed since last Wednesday...he was given Nitro [nitroglycerin] due to blood pressure of 190. He reports chest pain on and off since Friday. It is worse today. He was given aspirin by EMS [Emergency Medical Services]. He does report a history of MIs [myocardial infarction] but is unable to tell me the last time he had a stent or an MI ...wants to be transferred to [ named another hospital]..." The physician ordered lab work, chest X-ray, and ECG [electrocardiography]. No medication was ordered to address the pain. Follow up physician note revealed,"...Patient is adamant he wants to be transferred to [another hospital]...Patient was accepted to [named another hospital]...He will be transferred for emergent dialysis."

Patient #7 was transferred to another hospital on 02/14/2024 at 11:52 AM for continued treatment due to patient's personal choice.

There was no documentation in Patient #7's medical record that pain was assessed or treated after the initial triage assessment at 8:58 AM.

5. In an interview on 04/09/2024 at 9:32 AM, the Interim ED Director and the ED Nursing Manager both confirmed that neither Patient #5 nor Patient #7 had their pain reassessed at discharge. Both stated it was expected of ED staff to assess pain at triage, then at minimum every 2 (two) hours, unless the patient was administered pain medications, then assessments should be every hour, and at discharge.

In an interview on 04/09/2024 at 12:35 PM, the ED Medical Director stated that he expected nursing staff to assess pain at triage, at least every 2 (two) hours and then at discharge.

In an interview on 04/9/2024 at 3:10 PM, the Director of Informatics verified that after the pain medication was administered to Patient #1 on 2/14/2024 at 11:48 AM and when he reported no change in the pain at 12:57 PM, there was no documentation the continued pain was communicated to the physician. The Director of Informatics further verified the nurse documented Patient #1's pain as "9" at 5:32 PM and documented his pain as "8" at 6:41 PM, but no medication was administered after the Morphine Sulfate 4 mg IV was given at 3:52 PM, and that Patient #1's pain was not reassessed prior to discharge.

In an interview on 04/09/2024 at 3:20 PM, Registered Nurse (RN) #1 stated that he had worked in the ED for a little over 2 years. He knew that pain was checked at triage, then an hour after pain medication administration and every 1 to 2 hours after, depending on how the patient was doing. He stated that the pain was always reassessed at discharge. He happened to be the discharge nurse for Patient #7 and could not recall checking her pain level at discharge. He stated that it had been an oversight on his part. He stated that the electronic medical record (EMR) did prompt warnings to check pain levels but that the nurses had to manually go in and check them in the system. He was unaware of how many times he received training on pain assessment but figured he had received the training at hire.

In an interview on 04/09/2024 at 3:30 PM, RN #2 stated that she had been working in the ED for 7 years. She stated that pain levels were checked at triage, an hour after pain meds were administered, and if no pain meds had been administered then just "whenever the text turned red." The text would turn red in the EMR when something was overdue. She could not tell the surveyor the frequency of how often the pain levels needed to be assessed. She stated that it "should" be reassessed at discharge. RN #2 stated she recalled helping with Patient #7 but could not recall why his pain had not been reassessed at discharge. She could not recall receiving any pain assessment training other than upon hire.