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Based on document review and interview, nursing services failed to document pain assessment as ordered, pain assessment prior to pain medication administration, and document pain interventions and patient's condition in 1 of 10 (Patient 1) medical records reviewed.

The cumalative effects of these systemic problems resulted in the facility's inability to provide nursing care in a safe manner.

Based on document review and interview, nursing services failed to document pain assessment as ordered, pain assessment prior to pain medication administration, and document pain interventions and patient's condition in 1 of 10 (Patient 1) medical records reviewed.

1. Facility policy titled Pain Management, publication date: 02/17/2025, indicated under Procedures, C. Reassess and respond to patient's pain plan throughout the Registered Nurse's (RN) shift. Reassessment is based on intervention, delivery method, and progress towards functional goal. 2. Lippincott Procedures - Pain Assessment pediatric (lww.com): Pain Assessment, pediatric, Revised: May 19, 2025, under Introduction, A child's pain should be reassessed at designated intervals according to the type of pain intervention used (for example by the oral, IV, or transdermal route) to evaluate progress toward pain management goals; under Documentation, reassessment findings (as indicated), description of behavior, positions of comfort, activity level, pain management interventions. The policy lacked what designated intervals were established for assessment.

2. Facility policy titled, Scope of Assessment, publication date: 06/27/2024, indicated under V. Policy Statements, B. Reassessments continue throughout hospitalization at regularly specified times to determine the patient's response to treatment and/or when significant change occurs in the patient's condition or diagnosis.

3. Facility policy titled, Medication Administration and Management, publication date: 05/08/2023 under Monitoring, A. All team members shall monitor and document as appropriate the effects of medications administered, 1. Effects of pain medication are documented consistent with pain reassessment procedures.

4. Review of Patient 1's medical record indicated the following:
a. The patient was admitted on 06/26/2025.
b. Medical record indicated provider order on 06/26/2025 at 5:03 p.m. indicated pain assessment every 4 hours. At 11:19 p.m. the patient's pain score was 10/10; MR lacked documentation of interventions and patient condition.
c. On 06/27/2025 the patient's pain was not assessed from midnight until 7:00 a.m. The medical record lacked documentation of the one of six ordered pain assessments. At 6:35 a.m. Hydromorphone 0.6 mg intravenous push was administered, medical record lacked documentation of pain assessment prior to administration of medication. At 7:00 a.m. the patient's pain score was 8/10, the medical record lacked documentation of interventions.
d. The patient was discharged on 06/28/2025 in stable condition.

5. Interview with A5 (Nursing Practice Manager) on 07/09/2025 at approximately 1:10 p.m. indicated that the facility's policy does not specify when nursing is to reassess the patient's pain level after administration of medication or interventions. A5 indicated that nursing is to utilize nursing judgement of when to reassess pain. A5 confirmed the above policies referenced designated times.

6. Interview with A2 (Manager of Accreditation and Regulatory) and A8 (8 East Manager) on 07/09/2025 at approximately 6:31 p.m. confirmed the above findings in patient 1's medical record.

7. Interview with N2 (Registered Nurse) on 07/10/2025 at approximately 1:54 p.m. indicated they cared for patient patient 1 on 06/27/2025 and the patient had significant pain and pain control was a priority for the duration of their shift; N2 indicated the facility orientation did not include when to assess and reassess pain interventions.

8. Interview with N1 (Registered Nurse) on 07/17/2025 at approximately 5:02 p.m. indicated the facility orientation did not include when to assess and reassess pain interventions.