HospitalInspections.org

Based on interview and record review, the facility failed to implement their "Pain Management" policy for one of 30 sample patients (Patient 1), when Patient 1 was not provided pain medication for three hours and 58 minutes after arriving at the Emergency Department (ED), complaining of chest pain.

This failure resulted in Patient 1's chest pain to not be treated in a timely manner.

Findings:

On March 12, 2025, an unannounced visit was conducted at the facility for a complain validation survey.

On March 12, 2025, at 1 p.m., Patient 1's medical record was reviewed with the Director of Quality (DQ).

The facility document titled, "ED Provider Notes", dated March 2, 2025 at 6:32 a.m., was reviewed. It indicated Patient 1 presented to the ED on March 2, 2025 at 12:02 a.m., with a chief complaint of shortness of breath for one month.

The facility document titled, "Flowsheet History", dated March 2, 2025, at 12:08 a.m., was reviewed and indicted Patient 1 rated his chest pain seven of 10 on the pain scale (numerical tool used to assess intensity of pain).

The facility undated document titled, "Medication Administration Report," was reviewed and indicated, Morphine four milligrams (mg's, unit of measurement) Intravenous (IV, in the vein), was ordered and administered at 4 a.m., three hours and 58 minutes after Patient 1 presented to the ED with chest pain. There was no documented evidence pain medications were ordered or administered to Patient 1 prior to the Morphine.

On March 12, 2025, at 2:20 p.m., an interview was conducted with the DQ. The DQ stated, per the facility policy Patient 1 was not provided pain medication in a timely manner.

A review of the facility policy titled, "Pain Management,", revised August 2024, was reviewed and indicated, "Purpose: To ensure optimal patient comfort through a proactive pain control plan...The patient's right to pain management is respected and supported. This is accomplished by...effective pain management strategies and interventions...[Name of facility] staff will respond quickly to communication of unrelieved pain to the physician for resolution..."