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Based on record review and staff interviews, the facility failed to ensure that Emergency Department (ED) staff properly assessed and monitored pain levels for 4 (Patient (P)1, P3, P4 and P6) of 6 (P1-P6) patient charts reviewed. This deficient practice could result in inadequate pain management, delayed pain interventions, affect patient outcomes and satisfaction for all patients in the facility ED.

The findings are:

A. Record review of the facility's policy titled: "Pain Management, ADM POL 14-18" Effective date 01/2022 through 01/2025 stated the following:

1. "All patients admitted as inpatients and presenting to the emergency department shall be questioned as whether or not they are experiencing pain.

2. An age and ability-appropriate comprehensive initial pain assessment shall be conducted for any patient reporting or suspected of having moderate or severe pain. The comprehensive assessment shall include, to the extent relevant, intensity (using an age-appropriate pain scale when practical and available), site(s) quality (e.g. dull, sharp, throbbing, stabbing), radiation, onset (e.g. when did the pain start, is it increasing or decreasing). The details of the initial pain assessment may vary depending on the clinical presentation and the nature of the interaction. For example, a physician's note addressing the patient's pain as part of medical screening or a physical examination is considered a comprehensive pain assessment.

3. A reassessment for the presence and intensity of pain shall be performed at least once every shift for inpatients and extended-stay outpatients and following any intervention intended to lessen the patient's pain (for example, administration of pain medications, applications of cold packs, repositioning). The reassessment and documentation of the reassessment shall take place within the hour of the intervention that was performed to lessen the patient's pain (for example, administration of pain medications, applications of cold packs, repositioning). The documentation may be as simple as "patient sleeping comfortably following pain intervention."

B. Record review of P1's medical record revealed P1 arrived at the ED on 03/26/24 at 7:26 pm with complaints of severe abdominal pain at a level of 8 out of 10, (utilizing a numeric standardized adult pain scale of 0 to 10, with 0 being no pain, and ten being the worst possible pain) at 7:47 pm. Despite the patient reporting severe pain upon arrival to the ED, no documentation of a pain intervention was found in P1's medical record until 10:31 pm, several hours later, when P1 was given IV (a medical method that administers fluids, medications and nutrients directly into a person's vein) pain medication at 10:31 pm.

C. Record review of P3's medical record revealed P3 presented to the ED on 02/04/24 at 6:42 am with reports of abdominal epigastric (upper abdominal area) pain at a level of 7 out of 10 at 6:42 am, then at 7:01 am the patient reported an increased pain level of 8 out of 10, but no documentation of pain-relieving interventions was found in P3's medical record, nor did the medical record contain any documentation of a pain reassessment, and P3 left the facility against medical advice (AMA) on 02/04/24 at 8:44 am.

D. Record review of P4's medical records revealed P4 arrived at the ED on 08/01/24 at 9:17 pm with complaints of abdominal pain. The medical record did not contain any documentation of a pain assessment, or any pain-relieving interventions offered or provided to the patient.

E. Record review of P6's medical records revealed the P6 arrived at the ED on 04/14/24 at 1:31 pm and reported severe pain at a level of 8 out of 10 at 1:37 pm. P6 was reevaluated for pain at 1:39 pm, again reporting severe pain of 8 out of 10. P6's medical record did not contain any documentation of any pain-relieving interventions while P6 was in the ED or that a pain reassessment was completed despite P6 reporting severe pain shortly after arriving to the ED.

F. During an interview on 12/11/24 at 2:51 pm with S (staff) 4, clinical staff member, S4 stated the pain assessment policy requires an initial comprehensive pain assessment at each initial nursing assessment and again after one hour following any pain-relieving interventions to determine if the intervention was effective.

G. During an interview on 12/11/24 at 3:41 pm with S5, clinical staff member stated that the facility pain assessment policy requires an initial pain assessment during triage soon after patient arrives to the ED, using a standardized numeric scale, and a reassessment for pain one hour after the patient has been given pain relief interventions.