HospitalInspections.org

Based on document review and interview, it was determined that for 4 of 10 (Pt. #1, #2, #4 and #8) clinical records reviewed in the Emergency Department (ED), it was determined that the Hospital failed to ensure that the policies for pain assessment and documentation standards were followed, as required.

Findings include:

1. On 6/5/19 at approximately 2:00 PM, the Hospital's policy titled, "Nursing Assessment and Documentation Standards for Emergency Department" (dated 11/17) was reviewed and included, "... Documentation should reflect the on-going assessment of patient problems, interventions and evaluations. The emergency registered nurse (RN) collects patient data based on focused evaluation and documents relevant data... in the patient record... Waiting Room... Reassessments should include recheck of any abnormal vital signs (e.g. blood pressure, heart rate, respiratory rate, temperature), pain assessment and observations related to the chief complaint... Main Treatment Area... 2. Reassessment including vital signs should be done minimally every two hours while in the main treatment area or more frequently as appropriate... ESI (Emergency Severity Index/Ed triage algorithm that stratifies patient into five groups from 1 (most urgent) to 5 (least urgent) on basis of acuity and resource needs) ... level 3 patients should have vital signs every 1-2 hours, or more often as needed..."

2. On 6/5/19 at approximately 2:30 PM, the Hospital's policy titled, "Pain Assessment and Management" (dated 8/18) was reviewed and included, "... F. Reassess and document pain to evaluate the effectiveness of pain management interventions as determined by the individual patient status/need and as appropriate to the patient encounter. 1. Ongoing reassessments of adequacy of pain relief and presence of adverse effects are necessary to make appropriate adjustments to a patient's pain management plan. 2. The time to reassessment after pharmacologic intervention... a. Intravenous... 15-30 minutes...b. oral. 60-120 minutes..."

3. On 6/4/19 at approximately 11:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 68 year old male that presented to the ED on 3/4/19 at 4:32 PM, for medical evaluation with a chief complaint of chest pain and pain to the left arm. Pt. #1 was triaged at 3:43 PM and the pain documentation indicates that Pt. #1 had a score of 6 of 10 (1 no pain and 10 severe pain). Pt. #1 ESI rating was a 3. Pt. #1 clinical record lacked documentation of pain reassessment. Pt. #1 was in ED from 3/4/19 at 4:32 PM to 3/5/19 at 12:41 PM (9 hours and 9 minutes). Pt. #1 left the Emergency Department at 12:42 PM.

4. On 6/5/19 at approximately 11:30 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was a 52 year old male who came to the ED on 6/5/19 at 8:51 AM due to chest pain. The clinical record indicated that Pt. #2 was given morphine sulfate (narcotic pain medication) intravenous injection for chest pain on 6/5/19 at 9:48 AM. However, a pain reassessment was not completed and documented until 10:58 AM on 6/5/19 (40 minutes late).

5. On 6/5/19 at approximately 1:00 PM, the clinical record of Pt. #4 was reviewed. Pt. #4 was a 55 year old female who came to the ED on 3/4/19 at 4:09 PM due to chest pain. The clinical record indicated that Pt. #4 had an ESI rating of 3 and a pain level of 10 (1 having no pain and 10 as having severe pain) on 3/4/19 at 4:09 PM. The clinical record indicated that on 3/4/19 at 6:34 PM, Pt. #4 was given Tylenol (pain medication) by mouth. On 3/4/19 at 8:00 PM, the clinical record included, "I am leaving." However, Pt. #4's clinical record did not include a pain reassessment after administration of Tylenol.

6. On 6/5/19 at approximately 1:30 PM, the clinical record of Pt. #8 was reviewed. Pt. #8 was a 25 year old female who came to the ED on 3/5/19 due to general body aches. The clinical record indicated that Pt. #8 had an ESI of 3 and a pain level of 10 on 3/5/19 at 7:31 PM. The clinical record indicated that on 3/5/19 at 9:34 PM, Pt. #8 refused acetaminophen (pain medication). The clinical record on 3/6/19 at 12:49 AM included, "No answer when called from WA (waiting area)." However, the clinical record lacked documentation of Pt. #8's pain reassessment.

7. On 6/5/19 at approximately 11:30 AM and 2:30 PM, findings were discussed, and interviews were respectively conducted with E #7 (ED Charge RN/Registered Nurse) and E #6 (RN Manager of ED). E #7 stated, "There should be a pain reassessment 30 minutes after administration of intravenous pain medication." E #6 stated, "There should have been a (patient) reassessment, at a minimum, every 2 hours while in the ED." E #6 added that the assessment and reassessment should be documented in the patients' medical record.