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Based on a review of medical records, staff interviews, and policy titled "Pain Management Promise Package," it was determined that nursing services failed to complete pain severity assessments when pain medication was administered for one patient (P) (P#12) of 11 sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#10, P#11, and P#12).


Findings Included:


A medical record review revealed that P#12 was admitted to the facility on 5/22/25 at 10:45 a.m. with a diagnosis of Sickle Cell Crisis (a painful episode that occurs when abnormal sickle-shaped red blood cells block small blood vessels, leading to tissue damage and pain).


Additional review of the medical record for P#12 revealed the following:

" On 5/23/25 at 3:18 a.m., a provider ordered oxycodone-acetaminophen (also known as Percocet, a combination medication of an opioid and Tylenol used to treat moderate to severe pain), 5-325 mg, one tablet, every four hours for pain as-needed (PRN). The medical record failed to reveal a pain assessment associated with the administrated oxycodone-acetaminophen, 5-325 mg, doses dated for: 5/23/25 at 5:31 a.m. and 5/25/25 at 1:34 p.m.

" On 5/23/25 at 12:15 p.m., a provider ordered hydromorphone (also known as Dilaudid, an opioid medication used to treat moderate to severe pain), one mg, via intravenous (IV), every three hours PRN. The medical record failed to reveal a pain assessment associated with the administrated hydromorphone, one mg, doses dated for: 5/23/25 at 1:00 a.m., 5/23/25 at 3:58 a.m., and 5/23/25 at 7:02 a.m.

" On 5/23/25 at 12:15 p.m., a provider ordered hydromorphone, two mg, IV, every four hours PRN. The medical record failed to reveal a pain assessment associated with the administrated hydromorphone, two mg, doses dated for: 5/29/25 at 4:06 a.m. and 5/29/25 at 11:57 a.m.


A review of the facility's policy titled "Pain Management Promise Package," policy #18422151, last revised 6/25/25, revealed that the purpose of the policy was to detail the process for assessment, reassessment, and documentation of patient's pain goal each shift along with the reassessment documentation of patient's pain within one hour.
Continued review revealed, Standard Work: Pain Management, a comprehensive pain assessment and goal is a part of the nursing assessment and reassessment and should be performed.
Continued review revealed that if an intervention is performed, the patient's level should be assessed within one hour after intervention to determine the patient's response.


During an interview on 9/10/25 at 9:37 a.m. in a conference room, Registered Nurse (RN) MM said that when a nurse administers pain medication there is certain documentation that accompany' s it. RN MM said that first the nurse must assess the pain severity, frequency, location, and quality and administer pain medication that is appropriate per the medication profile ordered by the provider. RN MM said that after the pain medication is administered, the nurse should reassess the pain severity within one hour to see whether further intervention is necessary or not.


During an interview on 9/10/25 at 9:51 a.m. in a conference room, Nurse Manager (NM) DD said that her expectation of nursing documentation regarding pain is that the nurse should first assess the pain severity prior to administering medication. NM DD said that after the pain medication is administered the nurse should reassess for the pain severity within one hour and follow up as necessary. NM DD said that a pain assessment must be included in all nursing assessments and should be performed per unit policy. NM DD said that a full pain assessment should include the location, pain severity, frequency, and quality. NM DD said that simply documenting the pain score is not sufficient.