HospitalInspections.org

Based on record review and interview, nursing staff failed to evaluate the patient's care needs in regards to pain management and failed to document the patient's response to pain management interventions. Findings are:

-The patient presented to the Emergency Department on 12/18/2013 with a complaint of severe back pain following a fall suffered at home two days prior to arrival at the hospital. A CT scan of the lumbar spine showed evidence of acute L1 fracture. The patient was admitted to the hospital on an observation status and transported to the 4th floor at 0453 on 12/19/2013.

-The Director of Patient Safety/Quality Improvement stated on interview conducted on 5/6/2014 at approximately 10:15 AM that hospital policy requires a patients' pain status to be assessed when vital signs are completed. The patient is asked to rate their pain on a scale of 0-10. If pain medication is administered a nursing reassessment for the effectiveness of the medication is to be completed within an hour of the medication administration.

-Review of the nursing notes in the patient's medical record showed that pain status was assessed during the nursing admission interview initiated at 0453 on 12/19/2013. Pain status was not assessed again until more than 24 hours later, on 12/20/2013 at 0903. The patient reported pain to be 10/10. The patient was medicated, but there was no reassessment to determine the patient's response to this intervention.

-Vital signs were completed on 12/19 at 0817, 1631, and 1921; the patient's pain status was not assessed.

-Vital signs were completed on 12/20 at 0017 and 0339, the patient's pain status was not assessed.

-RN assessments were completed on 12/19 at 1924 and 12/20 at 0800; RN documentation indicates that pain was present with no details as to what was done about it.

The above findings were confirmed with the Director of Patient Safety/Quality Improvement in a telephone conversation on 6/6/2014 at approximately 12:00 PM.