Bringing transparency to federal inspections
Tag No.: A0395
Based on record review and interview, the hospital failed to ensure pain was reassessed after pain medication was given for three of 20 (Patients # 3, 4 & 17) records reviewed.
This failed practice had the likelihood that pain was not relieved or an optimal pain level was not achieved for patients # 3, 4 & 17.
Findings:
A policy titled "Pain Assessment & Management" showed after treatment, intervention, reassessment of pain, level of sedation and other adverse effects should occur within 60 minutes.
A review of the following patient records # 3, 4 & 17 showed there was no reassessment of pain medication after administration.
On 07/03/18 at 10:30 am, Staff E stated the expectation was for the nurse to reasssess pain after pain medication was given; if pain was reassessed within an hour the assessment would be documented.