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Based on policy and procedure review, medical record review, and staff interviews, nursing staff failed to assess and reassess a patient's pain per policy and follow pain medication physician orders for 1 of 3 patients with pneumonia (Patient #2).

The findings include:

Review on 06/13/2019 of an Emergency Department policy titled "Pain Assessment and Management" last revised 04/2016 revealed "...Assessment on admission to the Emergency Department for presence, absence, and history of pain using an age appropriate objective rating scale...Initial patient history will include the presence or absence of pain...Reassessment will include but may not be limited to after receiving pain medication or intervention (not to exceed two hours) and/or at discharge. Factors are to include but will not be limited to: ...i. Intensity...DOCUMENTATION Admission assessment of pain will be documented on facility specific forms (i.e. triage form). Reassessment will be documented as applicable on patient flow sheet and on the MAR (Medication Administration Record) ..."

Review on 06/13/2019 of an inpatient policy titled "Pain Management" last revised 05/2017 revealed "...Each patient will be assessed and monitored for the presence of pain...4. At regular intervals per the unit standard of care 5. With each new report of pain 6. After intervention - In the (Electronic Health Record Name) when a patient is given pain medication for pain, a task will be generated on the Patient Access List for the review of the medication effectiveness...E. Pain intervention options could include: 1. Administration of pharmacological agents, using 'as needed' or routine scheduling...Additional Alternative measures may include: 1. Giving additional ordered medication 2. Notification of the physician for new or alternate orders..."

Review on 06/13/2019 of a policy titled "Medication Use: Dose/Frequency Range Orders" last revised 06/2017 revealed "...The hospital's pain scale will be used to assess the patient and determine the severity of pain. For those patients unable to use the numeric scale, a visual aid will be used. For orders written as mild, moderate and/or severe the pain scale will be interpreted as below:...Mild 1-3 Moderate 4-7 Severe 8-10..."

Closed medical record review on 06/11-12/2019 of Patient #2 revealed a [AGE] year old female who arrived to the emergency department on 03/29/2019 at 0001. Review of the triage note at 0001 revealed Patient #2's chief complaint was, "...Patient was diagnosed with pneumonia at (Hospital Name) three days ago. Patient states the shortness of breath, fever, and chest pain has gotten progressively worse..." Review failed to reveal a triage pain assessment. Review of the physician note at 0037 revealed "...The patient presents with chest pain and Shortness of breath...States she has continued chest pain and shortness of breath...Nothing seems to relieve the pain . Currently describes severe sharp pain in the right side of her chest..." Review revealed Patient #2 had 10mg of IV (intravenous) Toradol (pain medication) at 0059 and 4mg of IV morphine (pain medication) at 0201. Review revealed no pain assessments or reassessment documented for Patient #2 before or after the medication administration. Review revealed Patient #2 had a chest x-ray and CT (computed tomography) scan of the chest that showed she had pneumonia and a pleural effusion. Review of the physician orders revealed Patient #2 had no pain medication orders for moderate (4-6) or severe (7-10) pain. Review revealed Patient #2 had Tylenol and Ibuprofen ordered for mild (1-3) pain. Review revealed Patient #2 was given 650mg of Tylenol at 0651 on 03/29/2019. Review revealed no pain assessment documented when Patient #2 was given Tylenol. Review of the pain reassessment at 0751 revealed a pain score of 3 out of 10. Review revealed Patient #2 underwent a thoracentesis (procedure to drain fluid out of lung) at approximately 0830 and was brought to the inpatient unit at approximately 1000. Review revealed at 1059 Patient #2 was given 650mg of Tylenol. Review revealed no documented pain assessment when Patient #2 was given Tylenol. Review revealed a pain reassessment of 3 out of 10 at 1159. Review revealed Patient #2 had a pain assessment at 1614 of 6 out of 10 (moderate pain). Review revealed Patient #2 received 600mg of Ibuprofen at 1652 and a reassessment of pain was not done until 2254 (6 hours and 2 minutes after the medication administration) when it was a 5 out of 10. Review revealed no documentation the nurse called the physician to clarify the order or get a new order to treat moderate (4-6) pain. Review revealed Patient #2 received Ibuprofen 600mg on 03/30/2019 at 0443 for a pain level of 6 out of 10. Review revealed no documentation the nurse called the physician to clarify the order or get a new order to treat moderate pain. Review revealed Patient #2 was discharged on [DATE] at 1500 to home.

Interview on 06/13/2019 at 1240 with RN #1 (Registered Nurse) revealed she did not recall Patient #2. Interview revealed normally pain assessments were done every four hours on the unit Patient #2 was on. Interview revealed pain assessments were done prior to administering a pain medication and a pain reassessment was done up to one hour after the medication was given. Interview revealed if a patient was not getting relief from their pain medication RN #1 would call the physician. Interview revealed RN #1 was not sure why Patient #2 did not have pre or post assessments on 03/29/2019, "I might have gotten busy." Interview revealed physicians wrote pain medication orders for mild moderate or severe pain. Interview revealed mild pain was 1-3, moderate pain 4-6 and severe pain 7-10. Interview revealed if a patient had a pain score of greater than what the pain medication was ordered for, RN #1 would give the patient the medication, reassess the patient's pain, and call the physician if the pain was not relieved.

Interview on 06/13/2019 at 1345 with the Chief Nursing Officer revealed the expectation for pain assessments were to be done per unit standard of practice. Interview revealed there should be a pre-assessment when administering the medication and a pain reassessment up to approximately 2 hours after the intervention. Interview revealed the physician decides the level of pain they will prescribe medication for. Interview revealed if a patient had a pain scale that was not addressed in the pain medication orders, the nurse should give the patient pain medication, reassess the patients pain, and call the physician to notify them about patient's pain.

NC 290