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WAGONER COMMUNITY HOSPITAL
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on record review and interview, the hospital failed to ensure reassessment of pain medication administration for five (Patient #1, 3, 4, 5, and #6) of ten patients
This failed practice has the likelihood to result in no assessment of a patient's clinical condition and delayed intervention.
Review of a facility policy titled "Assessment and Reassessment of Patient Care Needs" read in part, "reassessments should be documented as it relates to medication..." "Pain medication scale ratings should be used as appropriate"
Patient #1
Review of the electronic medication record (EMR) showed acetaminophen-hydrocodone administered for pain on 6/27/21 at 4:25 AM and pain reassessment not completed per facility policy.
On 6/28/21 at 1:37 PM, Staff B reviewed the EMR for Patient #1 and stated the pain reassessment was not completed per facility policy.
Patient #3
Review of the EMR showed morphine was administered for pain on 6/28/21 at 3:39 AM and pain reassessment not completed per facility policy.
On 6/28/21 at 1:49 PM, Staff B reviewed the EMR for Patient #3 and stated the pain reassessment was not completed per facility policy.
Patient #4
Review of the EMR showed morphine was administered for pain on 6/26/21 at 1:00 AM and pain reassessment not completed per facility policy.
On 6/28/21 at 1:55 PM, Staff B reviewed the EMR for Patient #4 and stated the pain reassessment was not completed per facility policy.
Patient #5
Review of the EMR showed acetaminophen-hydrocodone w administered for pain on 4/8/21 at 5:48 AM and pain reassessment not completed per facility policy.
On 6/28/21 at 2:13 PM, Staff B reviewed the EMR for Patient 5 and stated the pain reassessment was not completed per facility policy.
Patient #6
Review of the EMR showed morphine administered for pain on 5/1/21 at 4:11 AM and pain reassessment not completed per facility policy.
On 6/28/21 at 2:27 PM, Staff B reviewed the EMR for Patient #6 and stated the pain reassessment was not completed per facility policy.