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Based on interview and record review, the hospital failed to assess patient's response to interventions for five of 30 sampled patients (Patient 2, Patient 3, Patient 4, Patient 8, and Patient 11) when: pain reassessments were not completed timely after administration of PRN (as needed) pain medication. This failure resulted in nursing staff being unaware of pain medication effectiveness and had the potential for Patient 2, Patient 3, Patient 4, Patient 8, and Patient 11, to have continued pain.

Findings:

During a review of Patient 2's Medication Administration Record (MAR) dated, 9/12-9/14/24 MAR indicated, an order for "Acetaminophen (TYLENOL) tablet 650 mg" for mild pain, Frequency: every 4 hours PRN. MAR indicated, Tylenol was given on 9/13/24 at 0916, 09/13/24 at 1349, 9/13/24 at 2003, 9/14/24 at 0330, 9/14/24 at 0845, 9/14/24 at 1519, and 9/14/24 at 2325.

During a concurrent interview and record review on 10/29/24 at 1 p.m.., with Risk Management Clinical Analyst (RMCA), Patient 2's "Flowsheet History" (document of health record where nurses chart patients pain assessment) dated 9/12/24-9/15/24, was reviewed. Flowsheet indicated, on 9/13/24 Patient 2 was reassessed for pain score (rating of 1-10 based on severity of pain, 10 being highest pain possible) after administration at 0916, not until 1105 (1 hour and 49 minutes after). Flowsheet indicated, Patient 2 was reassessed after administration on 9/13/24 at 1349, not until 1527 ( 1 hour and 38 minutes after). ). Flowsheet indicated, Patient 2 was reassessed after administration on 9/13/24 at 2003, not until 2255 (2 hours and 52 minutes after). ). Flowsheet indicated, Patient 2 was reassessed after administration on 9/14/24 at 0330 not until 0732 (4 hours and 2 minutes after). ). Flowsheet indicated, Patient 2 was reassessed after administration on 9/14/24 at 0845 not until 1104 (2 hours and 19 minutes after). ). Flowsheet indicated, Patient 2 was reassessed after administration on 9/14/24 at 1519 not until 1843 (3 hours and 24 minutes). ). Flowsheet indicated, Patient 2 was reassessed after administration on 9/14/24 at 2325 not until 9/15/24 at 0806 (7 hours and 41 minutes after). RMCA stated, the above findings were documented as stated, in Patient 2's health record.

During a review of Patient 3's MAR dated 10/30/24, MAR indicated an order for Dilaudid (Narcotic medication. It can treat moderate to severe pain.) 0.5 mg, every 4 hours PRN for breakthrough pain. MAR indicated, Dilaudid was given at 0532 per Patient 3's request for 8/10 pain.

During a concurrent interview and record review on 10/30/24 at 10 a.m., with RMCA, Patient 3's "Flowsheet History" dated 10/30/24 was reviewed. Flowsheet indicated, Patient 3 received Dilaudid at 0532, and was not reassessed for pain until 0841 (3 hours and 9 minutes after). RMCA stated, there is no pain reassessment charted after 0532 administration of Dilaudid until 0841.

During a review of Patient 4's MAR dated 10/30/24, MAR indicated an order for Roxicodone (narcotic medication) 10 mg, every 4 hours PRN for pain. MAR indicated, Patient 3 was given Roxicodone on 10/30/24 at 0430.

During a concurrent interview and record review on 10/30/24 at 11 a.m., with RMCA, Patient 4's "Flowsheet History" dated 10/30/24 was reviewed. Flowsheet indicated, Patient 3 was given Roxicodone at 0430 with a pain score of 7/10. Flowsheet indicated, Patient 3 was not reassessed for the pain score until 0752 (3 hours and 22 minutes after). RMCA stated, Patient 4 was not reassessed after pain medication given at 0430 until 0752.

During a review of Patient 8's MAR dated 10/30/24, MAR indicated an order for Roxicodone 10 mg, every 4 hours PRN for pain. MAR indicated, Patient 8 was given Roxicodone on 10/30/24 at 0409.

During a concurrent interview and record review on 10/30/24 at 11:24 a.m., with RMCA, Patient 8's "Flowsheet History" dated 10/30/24 was reviewed. Flowsheet indicated, Patient 8 was given Roxicodone at 0409 and was not reassessed for pain until 0809 (4 hours later).

During a review of Patient 11's MAR dated 10/30/24, MAR indicated an order for Roxicodone 5 mg, give every 4 hours PRN for pain. MAR indicated, Patient 11 was given Roxicodone at 0421.

During a concurrent interview and record review on 10/30/24 at 11:50 a.m., with RMCA, Patient 11's "Flowsheet History" dated 10/30/24 was reviewed. Flowsheet indicated, Patient 11 was given Roxicodone at 0421 and not reassessed for pain until 0713 (2 hours and 52 minutes later). RMCA stated, Patient 11 was reassessed after the 0421 administration of pain medication at 0713.

During a review of the hospitals Policy & Procedure (P&P) titled, "Pain Management", dated 2022, the P&P indicated, "Reassessment. . .If the pain relief strategy included pharmacological agents [medications], reassessment of effect will occur within 60 minutes of medication administration".