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Based on documentation review, it was determined Hospital ED Staff failed to address Patient #1 pain in a timely manner/in accordance with Hospital policy/procedure.

Findings included:

Medical record documentation indicated Patient #1 presented to the ED at 2:57 AM and underwent a Triage Assessment at 3:15 AM. During the Assessment, he/she complained of a very sore and painful throat, inability to swallow, and body aches, indicated he/she was unable to open his/her mouth for an examination and/or throat culture, and spit oral secretions into a tissue. His/her vital signs were T =100.4, HR = 107, RR = 20, B/P = 119/64, and oxygen saturation level = 99%, he/she rated the pain at 10/10, and a physical examination revealed normal head and neck range of motion and a midline trachea. Patient #1 was triaged as an Emergency Severity Index (ESI) level 3 patient (a stable patient who can wait up to 2 hours for evaluation and treatment requiring multiple resources) and placed in a designated hallway treatment location in an Acute Area of the ED. Blood testing including a CBC and a chest x-ray were ordered. Pain medication was not ordered.

The Hospital's Policy/Procedure titled Triage Role Policy indicated patients in severe pain/distress as determined by clinical observation and/or patient rating of greater than or equal to 7 on a 0-10 pain scale will be triaged as ESI level 2 patient (a patient who requires evaluation and treatment requiring multiple resources within minutes).

Documentation indicated Patient #1 was evaluated by ED Physician #1 at 4:55 AM and the ED Physician found the Patient in no apparent distress, with complaints of severe throat discomfort, generalized myalgia, increasing neck swelling, hoarseness, and difficulty swallowing his/her saliva. ED Physician #1 noted Patient #1's medical history, vital signs and blood testing results and performed a physical examination. The examination revealed mild oropharyngeal erythema, a diffusely swollen and tender neck with normal range of motion, clear lungs, and equal breath sounds. ED Physician #1 thought Patient #1's symptoms were very concerning for abscess and ordered an IV antibiotic (Unasyn), an IV corticosteroid medication (Decadron), a CT scan of the neck (with contrast), and IV pain medication (morphine).

Documentation indicated Patient #1 was medicated with the morphine at 5:12 AM for 10/10 throat pain. Documentation also indicated Patient #1: rated his/her (throat) pain at 4/10 at 6:09 AM.