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Based on interview and record review, the facility failed to ensure the patient's right to receive an appropriate assessment and management of pain, and the facility policies and procedures (P&P) were followed for three of 30 sampled patients (Patient 3, 24 and Patient 26) seeking emergency care when:

1. Patient 26 presented to the emergency department (ED) with a burn to left leg and pain was not assessed during triage (a process used to assess patients' injuries or illnesses and determine the priority of care), or at any time during his ED visit.

2. Patient 24 presented to the ED for a headache and pain was not assessed during triage.

3. Patient 3 presented to the ED with palpitations (the sensation of feeling your heartbeat in an irregular, rapid, fluttering, or pounding way) and a headache and her pain was not assessed during triage.

These failures resulted in inconsiderate care and ineffective pain management of patient's presenting to the ED with self-reported pain, and the potential for avoidable patient suffering and negative consequences for patient health outcomes.

Findings:

1. During a review of Patient 26's, "History of Present Illness" (HPI - a document containing patient history and current medical issues), dated May 20, 2025, the "HPI" indicated, " ...Patient reports that a towel had caught fire on his left leg 2 days ago which caused the burn on his left shin ...He continues to have pain on the left leg. Now it is red and warm. He is concerned that it may be infected ...".

During a concurrent interview and record review on July 8, 2025, at 9:50 AM with the Emergency Department Educator (EDE), Patient 26's "ED Triage Vitals [Vital Signs- measurement of the body's most basic function including temperature, pulse, respiration rate, blood pressure, oxygen saturation and pain]", dated May 20, 2025, were reviewed. The "ED Triage Vitals" did not include a pain assessment (rating of how bad the pain is 0 to 10, where 0 is no pain and 10 is the worst pain imaginable, location of pain, type of pain, duration of pain, and what makes the pain better or worse). The EDE stated, there was no documented pain assessment by the triage nurse. Upon further review of Patient 26's "ED Vitals", the EDE stated, Patient 24's chart had no documented pain assessment during his visit to the ED. The EDE further stated, pain assessments are to be done by the triage nurse, with each set of vital signs, as needed and then documented in the patient's chart.

2. During a review of Patient 24's "HPI", dated June 10, 2025, the "HPI" indicated, Patient 24 presented to the ED on June 10, 2025, with complaints of headache and right sided abdominal pain and was and was admitted to the hospital with a diagnosis of diabetic ketoacidosis (DKA - a life-threatening complication of diabetes [a condition where your body has trouble managing sugar levels in your blood] that happens when your body doesn't have enough of a hormone called insulin (allows the body to use sugar as energy).

During a concurrent interview and record review on July 8, 2025, at 10:00 AM with the EDE, Patient 24's "Vitals Signs" , dated June 10, 2025, at 11:31 AM, were reviewed. The "Vital Signs", that were measured upon triage of Patient 24, did not include a pain assessment. The EDE stated, there was no documented pain assessment by the triage nurse. The EDE stated, the pain assessment is part of the triage and should be assessed and documented during the patient's triage assessment.

3. During a review of Patient 3's Face sheet (FS-a document that provides a summary of Patient's key information), the FS indicated, Patient 3 was brought to the facility on May 20, 2025, at 7:05 PM.

During a review of Patient 3's "HPI", dated May 20, 2025 at 8:10 PM , the "HPI" indicated, Patient 3 was brought into the facility from a dialysis (a medical procedure to remove waste and excess fluid from the blood when the kidneys are no longer filtering the blood) clinic, because Patient 3 began experiencing Palpitations (the sensation of feeling your heart beat in an irregular, rapid, fluttering, or pounding way) and Head Ache. Patient 3 was found to be in Supraventricular Tachycardia (a heart rhythm disorder causing a rapid heartbeat, typically originating in the upper chambers of the heart).

During a concurrent interview and record review on July 7, 2025, at 2:34 PM with the EDE, the "Vital Signs" were reviewed. The initial vital signs taken on May 20, 2025, at 7:08 PM, indicated no pain assessment was done. The first pain assessment done by nursing staff was until May 20, 2025, at 9:00 PM. The EDE stated the nurses are supposed to do a pain assessment when the patient first comes in or during triage.

During an interview with Registered Nurse (RN1) on July 8, 2025, at 9:40 AM, RN 1 stated, the nursing staff was expected to do a pain assessment when patients first come in or during the triage process. RN 1 stated, that a patient is seen by a provider and the patient is medicated, the nursing staff have 1 hour to document a reassessment of pain.

During an interview with the Director of Emergency Department (DED) on July 8, 2025, at 2:11 PM, the DED stated, it is expected for the nurses to assess pain level with the vital signs and during triage, even if the patient cannot verbally state their pain, the nursing staff can use the FLACC [Face, legs, Activity, Cry, and Consolability - used to assess pain in patients' who cannot express their pain in words) Pain Scale, Critical Care Pain Observation Tool (CPOT - used to assess pain in critically ill patients who cannot communicate pain), Wong Baker Face (uses pictures showing facial expressions from smiling and happy to a crying, sad face). The DED, further stated pain assessment is highly important because it can affect the patient's overall condition and vital signs.

During a concurrent interview and record review with the DED on July 8, 2025, at 2:25 PM of the facility's policy and procedure (P&P) titled "Pain Assessment and Management" dated July 3, 2019, was reviewed. The P&P indicated, " ...D. Pain is collected, assessed and reassessed: 1. On admission to the hospital or clinic 2. With each set of routine vital signs, pain is assessed as the 5th vital sign ..." The DED stated, the P&P was not followed, and nursing staff are expected to perform pain assessment with the vital signs.

During a concurrent interview and record review with the DED on July 8, 2025, at 2:26 PM of the facility's P&P titled "Patient rights" dated May 26, 2014, was reviewed. The P&P indicated, "... 21. Be informed of the right to have pain treated as effectively as possible ...25. Receive appropriate assessment of pain and optimum management of pain ...". The DED stated, the Patient Rights "P&P" was not followed and should have been. The DED stated, ED triage assessments need to be focused on the patient's chief complaint, and pain was an important piece of the assessment, especially when the patient has presented to the ED with a complaint of pain. The DED further stated the patients' pain assessment was highly important because pain can affect a patient's physical health during an emergency and the patient's overall wellbeing.