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Based on policy review, medical record review, and interviews the Hospital failed to ensure patients received adequate pain management and reassessment for 2 (Patient 7 and 8) of 12 patients reviewed. This deficient practice has the potential to affect all patients and may interfere with the patients' functional capabilities, delayed care progression and other adverse outcomes.

Findings Include:

Review of the Facility policy titled; "Pain Management." Last Revised 03/2021 "Purpose" Providence Medical Center respects and supports the rights of patients to safe, timely, and effective pain management. We place emphasis on improving the outcomes of pain management including comfort, managing side effects and complications, and patient satisfaction. Patient age, developmental status, physical, emotional, cultural, spiritual, and cognitive condition, and preferences shall be considered. Patient participation in the pain management process is imperative and expected.

Procedure:
1. Assess for pain using a pain scale (numeric, visual analog, or text based) consistently as follows:
1.1 Upon all initial assessments, including emergency department visits and at time of admission.
1.2 Before and after any pain-producing treatment or procedure
1.3 With each new report of pain
1.4 With routine vital signs and PRN
1.5 After each pain management intervention once sufficient time has elapsed for the treatment to reach peak effect, the goal is reassessment and documentation within 1 hour of intervention. Documentation should include the patient's response to the intervention and any side effects or adverse response.

Patient 7

Review of Patient 7's discharged medical record showed 27-year-old 39 weeks pregnant G4P3003 (currently pregnant, three full term births, three living children) female admitted to the hospital in active labor on 10/03/22. Patient had an Estimated Date of Delivery of 10/6/22.

Review of Patient 7's Medication Administration Record shows an order for Hydrocodone Acetaminophen 5/325 1 tablet every 4 hours as needed for severe pain level 7-10.

Review of Patient 7's "Flowsheet" for the dates of service 10/03/22 to 10/05/22 showed the nursing staff did not reassess pain level or check for effectiveness of Pain medication.

On 10/03/22 Hydrocodone Acetaminophen 5/325 mg 1 tablet administered at 7:55 PM Patient 7's pain level was rated at 5. Patient 7's pain level was not reassessed within one hour for effectiveness of pain medication.

On 10/04/22 Hydrocodone Acetaminophen 5/325 mg 1 tablet administered at 3:46 AM, 8:25 AM, at 8:03 PM, Patient 7's pain level was not reassessed within one hour for effectiveness of pain medication.

On 10/05/22 Hydrocodone Acetaminophen 5/325 mg 1 tablet administered 4:52 AM. Patient 7's pain level was not reassessed within one hour for effectiveness of pain medication.

Patient 8

Review of Patient 8's discharged medical record showed a 69-year-old male admitted to the hospital on 10/01/22 with a past medical history of congestive heart failure (CHF), End stage Renal Disease (ESRD), recent right below the knee amputation (BKA), Chronic Obstructive Pulmonary Disease (COPD), diabetes mellitus, Coronary Artery Disease (CAD) who complains of whole-body pain and also chest pain 10 out of 10 as sharp.

Review of Patient 8's Medication Administration record shows an order for Oxycodone 30 mg immediate release table 1 tablet by mouth every 6 hours as needed for severe pain level 7-10; Dilaudid injection 1 mg intramuscular every 3 hours as needed for pain.

Review of Patient 8's "Flowsheet" for the dates of 10/01/22 to 10/04/22. showed the nursing staff did not reassess pain level or check for effectiveness of Pain medication.

On 10/01/22 Dilaudid 1 mg administered at 4:27 PM, 7:39 PM. Patient 8's pain level was not reassessed within one hour for effectiveness of pain medication.

On 10/02/22 Oxycodone 30 mg administered at 10:03 AM. Patient 8's pain level was not reassessed within one hour for effectiveness of pain medication.

On 10/03/22 Oxycodone 30 mg administered at 2:33 PM, 9:57 PM. Patient 8's pain level was not reassessed within one hour for effectiveness of pain medication.