HospitalInspections.org

Based on policy review, medical record review, and interview, the facility failed to ensure patients were assessed and had management of their pain for 1 of 4 (Patient #1) sampled patients.

The findings included:

1. The facility's "Assessment and Management of Pain" policy revealed, "...Each patient...has the right to appropriate assessment and management of pain...A patient's report of pain will be accepted and respected as the key indicator of the amount of pain he/she is experiencing...The Numeric Pain Intensity Scale (NPIS), is a subjective scale where a patient communicates his/her current level of pain...rate the pain level on a scale of 0 to 10...Zero represents no pain; a rating of 5 indicates the patient has moderate pain, and a 10 represents severe pain...If a patient is given pain medication...the Nurse should reassess the patient within two hours to determine the effectiveness of medications and/or interventions..."

2. Medical record review for Patient #1 revealed an admission date of 9/23/19 with diagnoses which included Major Depressive Disorder and Hypokalemia (low level of potassium in the blood).

The Admission History & Physical dated 9/24/19 revealed, "...admitted last night and fell early morning today and had laceration (deep cut) over her L [left]-eyebrow...had sutures placed...also c/o [complained of] L-shoulder pain following her fall..."

The physician orders dated 9/24/19 revealed Patient #1 had naproxen (treats fever and pain) 500 mg (milligrams) ordered to be given twice a day at 9:00 AM and 9:00 PM; lidocaine topical 5% film (local anesthetic) apply daily at 9:00 AM and remove at 9:00 PM; and acetaminophen 650 mg every 4 hours PRN (as needed) for pain.

Review of the "DOCUMENTED RESPONSE REPORT" revealed on 9/24/19 at 8:34 PM, Patient #1 was given a PRN dose of acetaminophen 650 mg for a Pain Score of 6 in her left shoulder. The Pain Level Re-Assessment was not documented until 9/25/19 at 10:26 AM.

Review of the "DOCUMENTED RESPONSE REPORT" revealed on 9/26/19 at 3:18 PM, Patient #1 was given a PRN dose of acetaminophen 650 mg for a Pain Score of 8 in her left shoulder. The Pain Level Re-Assessment documented at 4:32 PM revealed a Pain Score of 7 and Pain Not Relieved. There was no evidence the nurse notified the physician of the patients unrelieved pain.

Review of the Nursing Progress Note dated 9/27/19 at 1:54 PM under the Narrative Summary revealed, " ...Pain in left shoulder 9/10, medication ineffective ..." There was no documentation a PRN medication was administered on 9/27/19 or the nurse notified the physician the pain medication was ineffective.

3. In an electronic message on 5/11/2020 at 4:07 PM, the Director of Quality verified the pain level re-assessment was not documented within the 2 hour time frame on 9/24/19 and there was no evidence the nurse gave a PRN medication on 9/26/19 or communicated with the physician concerning the patient's unrelieved pain on 9/26/19 and 9/27/19.