The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on document review and interview, it was determined that the Hospital failed to ensure that a thorough pain assessment and re-assessment was done before and after medication administration for 2 (Pt. #1, Pt. #3) of 4 patients reviewed for pain assessment. This has the potential to affect 2 patients in the Telemetry Unit.

Findings include:

1. The clinical record of Pt #1 was reviewed on 02/13/19. Pt #1 was a [AGE] year old male admitted on [DATE] at 4:04 PM with a diagnosis of acute coronary syndrome (blockage of one or more arteries that supply blood to the heart) with hypertension. Pt #1 was discharged home on 10/18/18 at 5:03 PM.

- The Emergency Department (ED) initial nursing notes dated 10/15/18 at 6:06 PM included, "Pain present, gradual onset, pain scale intensity 8 out of 10 (severe pain) ...pain medication administered per physician order 6:10 PM ..."

- The Emergency Department (ED) nursing notes dated 10/15/18 at 6:32 PM included, "Received pt. [Patient] with c/o [complaints of] chest pain and SOB [shortness of breath] started today. Per pt. [Patient] has hx/o [history of] ...labs drawn and sent ...medications given as ordered ...will continue to monitor ..."

- The ED pain re-assessment notes dated 10/15/18 at 7:00 PM included, "Pain reassessment: left blank with no documentation ...the vital signs sheet indicated score of 2 out of 10 (mild) discomfort ..."

- The ED nursing notes dated 10/16/18 at 2:10 AM included, "Pt. [Pt. #1] was transported to the admitting floor in stable condition ..."

- The Telemetry Unit nursing notes dated 10/16/18 at 2:15 AM included, "Received patient [Pt. #1] from ER ...alert, skin warm and dry to touch, respiration not labored ...history of chest pain and SOB [shortness of breath] ...quiet and not in any distress ..."

- The Telemetry Unit pain assessment flow sheet dated 10/16/18 at 2:36 AM included, "Are you in pain or discomfort: Yes ...pain intensity: (0-10): No documentation."

- The nursing plan of care dated 10/16/18 - 10/18/18, was reviewed. There was no notes related to pain management.

2. On 02/13/19 at approximately 1:30 PM, the clinical record for Pt. #3 was reviewed. Pt. #3 was a [AGE] year old male admitted on [DATE] at 2:15 AM with a diagnosis of Congestive Heart Failure (insufficient pumping of blood to heart).

- The admitting physician order notes dated 02/07/19 at 10:00 PM included, "Administer Tylenol (reduces pain) 500 mg [milligram] for pain ..."

- The medication administration record notes dated 02/12/19 at 10:49 PM included, "Administration of Tylenol 500 mg [milligram] ..."

- The pain assessment flow sheet dated 02/12/19 at 10:49 PM included, "Pain intensity score 7 out of 10 (severe pain)...pain re-assessment evaluation was left blank with no documentation ..."

3. On 02/14/19 at approximately 12:30 PM, the Hospital policy titled, "Pain Assessment, Re-assessment and Management" dated 10/2017 was reviewed. The policy included, "Policy ...patient's right to optimal pain assessment and management ...Procedure: ...if pain is present in the patient, it is responsibility of clinical staff to conduct an in depth clinical assessment of the pain, and periodic reassessments of the patient ...Patient will undergo reassessment of pain at least once per shift and after every pain control mechanism ..."

4. On 02/13/19 at approximately 1:25 PM, an interview was conducted with the Charge Nurse (E #3). E #3 stated, "I make sure to assess the pain on every shift especially those admitted with chest pain and on electronic monitor. Prior to administering the pain medication I document the pain intensity score, and 30 minutes after medication administration I do the re-assessment of pain to verify if the pain is relieved."

5. On 02/14/19 at approximately 9:57 AM, an interview was conducted with the Registered Nurse (E #10). E #10 stated "If the pain medication is administered, we must do a pain intensity assessment both initially and re-assessment after the medication is administered. I do not recall re-assessing the patient (Pt. #1) after medication administration."

6. On 02/15/19 at approximately 10:20 AM, an interview was conducted with Director of Quality/Interim CNO (E #8). E #8 stated, "Yes, definitely it is important to do initial pain assessment and post medication administration re-assessment. We will be providing training to all our nurses, we are working on our quality improvement process ..."