HospitalInspections.org

Based on policy review, record review, and interviews, the facility failed to monitor the effectiveness of pain medication and failed to provide reassessments of pain levels for two patients (#1 and #2) of 14 patients reviewed for pain management.

The findings included:

Review of facility policy titled "Pain Management" effective date February 2015, revealed "...Patients have the right to appropriate assessment and management of pain...Purpose...To determine effectiveness of analgesia and other pain control measures/interventions...Re-assessment of pain will be performed within one hour of pharmacologic (medication) and non-pharmacologic (use of relaxation, counseling, repositioning, massage or other intervention that do not involve administering medication to relieve pain) intervention which will reflect effectiveness of intervention..."

Medical record review revealed Patient #1 was admitted to the facility on 6/12/17 with diagnosis of Left Thyroid Nodule, Possible Follicular Carcinoma, and had a Total Thyroidectomy surgical procedure performed on 6/12/17.

Medical record review of a nursing assessment dated 6/12/17 at 1:58 PM revealed the Patient #1 complained of a pain level of "7" (on a scale of 1-10 with 10 being the most severe pain) and the patient was medicated with oral Methadone (pain medication) 20 milligrams (20 mg). Continued review revealed the patient's pain was not reassessed until 6/12/17 at 5:24 PM (3 hours 26 minutes later). Further review revealed the patient complained of level 4 pain on 6/12/17 at 5:24 PM and was medicated with oral Oxycodone (pain medication) 30 mg and the patient's pain was not reassessed until 6/12/15 at 11:39 PM (5 hours later). Further review revealed the patient complained of a pain level of 4 on 6/12/15 at 11:39 PM and was medicated with oral Oxycodone 30 mg and Methadone 20 mg and the patient's pain was not reassessed until 6/13/17 at 4:06 AM (5 hours 26 minutes later). Further review revealed the patient complained of a pain level of 7 on 6/13/17 at 4:06 AM and was medicated with Dilaudid (pain medication) 1 mg intravenously (injected into the patient's blood stream) and the patient's pain was not reassessed until 6/13/17 at 8:10 AM (4 hours later).

Medical record review revealed Patient #2 was admitted to the facility on 9/4/17 with diagnosis of Left Hip Pain after a fall.

Medical record review of a nurses assessment dated 9/5/17 at 10:03 AM revealed Patient #2 complained of a pain level of 10 and the patient was medicated with morphine (pain medication) 2 mg IV. Further review of the medical record revealed the patient's pain was not reassessed until 9/5/17 at 2:07 PM (4 hours later). Continued review revealed the patient complained of a pain level of 6 on 9/5/17 at 2:07 PM and was medicated with Norco (pain medication) 5 mg plus Acetaminophen (Tylenol) 325 mg and the patient was not reassessed until 9/5/17 at 7:51 PM (5 hours 44 minutes later).

Interview with Licensed Practical Nurse (LPN) #1, in the administration conference room, on 12/7/17 at 9:26 AM revealed the LPN cared for Patient #1 on 6/12/17 and 6/13/17 and she reassessed Patient #1's pain frequently, but did not document the pain score within an hour after administering pain medication. Continued interview revealed "...[the patient] was very sleepy and drowsy after surgery...I was afraid to give her more medication as she was already so sleepy...she did not appear to be in any pain...she was asleep so I did not arouse her to ask about pain..."

Interview with the Risk Manager on 12/7/17 at 10:30 AM, in the conference room, confirmed the facility failed to document pain reassessments for Patient #1 and Patient #2 within one hour following pharmacological interventions for pain management and the facility failed to follow facility policy.