HospitalInspections.org

Based upon document review and interview, the Registered Nurse failed to follow hospital policy and evaluate the pain level of each patient arriving to the ED (Emergency Department) for 5 of 10 medical records (MR) reviewed (Patients #1, 3, 4, 7 & 9).

Findings include:

1. Review of the policy/procedure Triage (revised 9-17) indicated the following: "All patients presenting to the [facility] Emergency Department will be triaged by a Registered Nurse (RN)..." and lacked documentation indicating each patient's pain level will be assessed and documented at the time of triage.

2. Review of the policy/procedure Prescribing Opioids for Patients in the Emergency Department (revised 1-18) indicated the following: "Pain will be assessed and documented at triage, after intervention and at discharge."

3. Review of the MR for Patients #1, 3, 4, 7 and 9 lacked documentation indicating the patient's level of pain was assessed and documented by a Registered Nurse at the time of triage.

4. On 7-12-18 at 1310 hours, the Executive Director of Quality, staff A1 and the ED Manager, staff A3 confirmed the MRs for Patients #1, 3, 4, 7 and 9 lacked documentation indicating a pain assessment was performed at the time of triage.