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ADVOCATE CONDELL MEDICAL CENTER
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on document review and interview, it was determined for 1 of 1 (Pt #1) records reviewed of patients with documented pain, the Hospital failed to ensure monitoring and documentation of the patients' pain as required.
findings include:
1. Hospital policy entitled, "Patient Nursing Assessment and Reassessment." (undated) required, "Procedure: A. Initial Admission Nursing Assessment...4. The RN performs the initial admission nursing assessment...The information gathered during the admission assessment includes but not limited to...d. Pain...B. Ongoing nursing Assessment...3. Pain will be assessed minimally with every recording of vital signs..."
2. Hospital policy entitled, "Pain Management," (review date 9/4/15) required, "Process: 1. Pain intensity ratings are recorded during the admission assessment ...2. b. A numeric rating scale where 0 = no pain and 10 = worst pain ever...K...5. Document pain intensity..."
3. The clinical record of Pt #1 was reviewed on 9/21/16. Pt #1 was a 57 year old female that presented to the Emergency Department (ED) via ambulance on 1/18/15 at 5:45 PM with...pain 10/10 and with complaints of chest pain, chronic renal insuffiency and weakness. Pt #1 was triaged as a level 2 out of 5. Pt #1 was offered Norco (pain medication) at 8:05 PM (refused) and given 324 mg chewed aspirin (4 time 81 mg) at 9:00 PM. Nursing documentation (undated and untimed) indicated, "Pt states she takes Norco at home for arthritis pain. When offered Norco here, she refused and is requesting IV narcotics."
4. ED nursing documentation dated 1/18/15 at 9:32 PM included, "...Pt states is having back pain and is requesting pain medication. Pt offered medication per MAR (medication administration record)." The documentation did not include an assessment of Pt #1's pain when requesting pain medication.
5. Pt #1's clinical record contained reassessments of Pt #1's vital signs at 7:35 PM, 8:35 PM, and 11:46 PM but did not include a reassessment of Pt #1's pain level.
6. The Emergency Department E#2 (RN) on duty 1/1/15 was interviewed on 9/22/16 at approximately 8:15 AM. E#2 (RN) stated according to her documentation the patient's pain was not reasesed after 5:45 PM.