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Based on interview and record review, the hospital failed to ensure the nursing staff conducted the pain assessment for one of five sampled patients (Patient 1) as per the hospital's P&P. This failure posed the potential to result in poor health outcomes to the patient.

Findings:

Review of the hospital's P&P titled Assessment, Reassessment, and Data Collection, Policy dated 1/18/24, showed the following:

* The provision of care, treatment, and services to the hospital patients includes the reassessment of the patient's condition and response to interventions.

* Patient assessment, reassessment, and screenings shall be performed by a RN.

* The reassessment is subsequent to admission and baseline/initial assessment, completed in accordance with unit frequency parameters.

* The data collection includes subject and objective data, including vital signs such as temperature, respiratory rate, heart rate, blood pressure, and pain level using an age or condition appropriate pain scale.

* The reassessment frequency parameters for adult ICU patients include to reassess the vital signs including pain every two hours. The response to pain management is to be reassessed when the condition warrants and as ordered.

Review of the hospital's P&P titled Pain Management dated October 2021 showed the following:

* The provider or RN is responsible for determining the appropriate screening tool/scale to be used, which includes

- Numerical rating scale: a numeric pain assessment tool in which patients are asked to verbally rate their current pain intensity on a scale of zero to 10 with zero being no pain and 10 being the worst possible pain.

- Critical-care Pain Observation Tool (CPOT): a behavioral scale used to quantify pain by using four categories: facial expression, body movements, muscle tension, and compliance with the ventilator or vocalization of the extubated patient. Presence of pain is suspected when the CPOT score is greater than two or when the CPOT score increases by two or more.

* The patients' response to pain intervention shall be evaluated and documented in a timely manner.
* When pain is present, a detailed assessment shall be performed to include the following parameters: pain intensity, pain quality, location, onset, duration, variation, and patterns, alleviating and aggravating factors, present pain management regimen and its effectiveness, and patient's pain goal.

* The ongoing assessment of pain is part of the vital sign measurement at intervals depending on the unit's routine assessment schedule, per patient's request, and/or necessity.

* The assessment and reassessment regarding pain management will be entered in the electronic medical record.

On 10/17/24 at 0938 hours, an interview and concurrent review of Patient 1's closed medical record was conducted with the Director of Nursing Quality Admin and Nursing Health Coordinator.

Patient 1's closed medical record showed Patient 1 admitted to the adult ICU on 9/17/24 at 1411 hours. The patient was transferred to the step-down unit on 9/18/24 at 2310 hours.

Review of the documentation for pain assessment and management showed the following:

* On 9/17/24 at 1406 hours, the patient's CPOT score was 7. The pain location was unable to be assessed. The patient was restless and unwilling to follow commands.

* On 9/17/24 at 1702 hours, the patient's pain level was 10 out of 10. There was no documentation of pain location, quality, or pain pattern. The MAR showed documented hydromorphone (a highly potent opioid medication) 0.2 mg IVP was adminstered to the patient.

* On 9/17/24 at 1720 hours, the patient's pain level was 10 out of 10. The sections of pain quality and acceptable pain were blank.

* On 9/17/24 at 1824 hours, the patient's pain level was 10 out of 10. The patient had pain to the head and the pain was constant. The sections of pain quality and acceptable pain were blank. The MAR showed the patient received oxycodone (a potent opioid medication) 5 mg orally on 9/17/24 at 1824 hours.

* On 9/17/24 at 1900 hours, the patient's pain level was zero. There was no documented evidence the nursing staff conducted the pain assessment for the patient from 9/17/24 at 1915 hours to 9/18/24 at 0142 hours, and on 9/18/24 from 0415 hours to 0800 hours.

* On 9/18/24 at 1812 hours, the patient's pain level was nine out of 10 and the patient's acceptable pain level was three out of 10. The section of pain pattern was blank. The patient was given an oral analgesic pain medication.

* On 9/18/24 at 2325 hours, the patient's pain level was eight out of 10. The sections of pain location, quality, and pattern were blank.

The Director of Nursing Quality Admin confirmed the findings.

On 10/17/24 at 1500 hours, during an interview with the Director of Nursing Quality Admin for the adult ICU patient's pain management and frequency of pain reassessment, the Director of Nursing Quality Adm stated for IV pain medication, the pain reassessment is conducted within 30 minutes. The Director of Nursing Quality Adm confirmed the hospital's P&P related to Assessment, Reassessment, and Data Collection was not specified to reassess the pain in 30 minutes after the administration of IV pain medication.

Based on record review and interview, the hospital failed to ensure the nursing staff administered the pain medication for one of five sampled patients (Patient 1) as per the physician's order. This failure created the risk of poor health outcomes for the patient.


Findings:

Review of the hospital's P&P titled Pain Management dated October 2021 showed to provide guidelines on the Pain Management Program including treatment. The pain management will utilize the inpatient pain management order set embedded in the EHR to maximize non-pharmacological and non-opioid treatment options. The initial screening, assessment, reassessment, treatment, and patient/family education regarding pain management will be entered in the electronic medical record. The treatment plan shall state objectives by which the treatment plan can be evaluated, such as pain relief.

On 10/17/24 at 0938 hours, an interview and concurrent review of Patient 1's closed medical record was conducted with the Director of Nursing Quality Admin and Health Facility Consultant.

Patient 1's closed medical record showed Patient 1 admitted to the adult ICU on 9/17/24 at 1411 hours.

Review of the MAR Summary dated 9/17/24, showed Patient 1 had two pain medications ordered as follows:

* Oxycodone 5 mg oral Q 4 hours, as needed for pain level from 5 to 10.

* Hydromorphone 0.2 mg IVP, as needed for breakthrough pain that was unrelieved by non-opioids and oral opioids (of ordered).

Review of the pain assessment dated 9/17/24 at 1702 hours, showed Patient 1's pain level was 10 out of 10.

Review of the MAR showed hydromorphone 0.2 mg IVP was administered to the patient on 9/17/24 at 1702 hours.

Review of the pain assessment showed on 9/17/24 at 1720 hours, the patient's pain level was 10 out of 10 which was the same pain level before the hydromorphone was administered to the patient. There was no documented evidence the nursing staff reported this treatment result to the provider for further management plan.

Review of the pain assessment showed on 9/17/24 at 1824 hours, Patient 1's pain level was 10 out of 10.

Review of the MAR showed on 9/17/24 at 1824 hours, oxycodone 5 mg was administered to the patient orally.

However, there was no documented evidence to show the reason why hydromorphone was administered to Patient 1 on 9/17/24 at 1702 hours, not following the physician's order to administer hydromorphone for the breakthrough pain that was unrelieved by oral opioids.

The Director of Nursing Quality Admin confirmed the findings.