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Based on document reviews and interviews, nursing staff failed to ensure pain evaluations, re-evaluations and interventions were completed according to standards of practice, in three of ten patient records reviewed (Patients #3, #6 and #10).

Findings include:

Facility policy:

The Pain Management policy read, all patients have the right to an accurate assessment and management of their pain. The caregiver assures that patients who experience pain, or at risk for pain are reassessed and treated appropriately and quickly. The patient may be monitored for pain: during hourly rounding; whenever an intervention or treatment is provided to relieve pain.

Pain reassessment is individualized to occur at the time that caregivers expect the intervention to begin relieving the patient's pain and discomfort. In general, reassessment is expected approximately 30 minutes after an injectable pain medication is administered, and 60 minutes after an oral pain medication is administered.

Pain is assessed and treated throughout the patient's course of treatment and stay in the facility.

General guidelines for interpretation of patient's pain level (0-10), and treatment per physician orders, as follows:

0 = no pain
1-3 = mild pain
4-6 = moderate pain
7-10 = severe pain

The policy also read, to consider non-pharmacological pain interventions, such as distraction, relaxation techniques, massage, positioning, and heat/cold for patient. Pain reassessment is based on the expected time of medication peak effect and route administered.

The Patient Assessment and Reassessment policy read, all patients will receive an initial nursing assessment and subsequent reassessment, based on individual needs including physical status. The assessment process determines the need for care and/or treatment, they type of care to be provided, and the patient's needs through the continuum of care. Reassessment for inpatients will include the following information: for nursing, patient reassessment or data collection will occur at a minimum of every shift. Reassessment must occur by an RN every shift or more frequently as indicated by the patient's condition.

1. Nursing staff did not ensure patients' pain was assessed and treated according to standards of care.

a. Review of Patient #3's medical record revealed the patient was admitted on 12/7/18. According to the History and Physical, dated 12/7/18, Physician #8 documented the plan for the patient's alcohol pancreatitis (pancreas inflammation), was intravenous fluids and pain management.

On 12/8/19 at 8:00 a.m., Registered Nurse (RN) #7 documented the patient's pain goal was a zero.

On 12/8/19 at 8:45 p.m., RN #9 documented in the nursing notes, the patient's pain level was reported as a five out of ten on a numeric pain scale and the patient's pain goal was zero. According to policy, a five pain level was considered to be moderate pain.

There was no evidence documented in RN #9's nursing assessment and the patient's medication administration record (MAR) which showed the nurse offered or provided interventions to relieve Patient #3's reported pain.

b. Review of Patient #6's medical record revealed the patient was admitted for right hip pain after a fall. Review of the patient's History and Physical, dated 3/1/19, showed the patient had a right introchanteric (femur) fracture. Patient #6 had surgery to repair the fracture the same day.

On 3/3/19 at 8:00 p.m., RN #10 documented Patient #6's pain intensity was at a six out of ten on the numeric scale. According to policy, the patient had a moderate level of pain. The patient's nurse documented the patient's right hip was aching and cramping. RN #10 documented interventions used to manage the patient's pain were dimming the lights, cold therapy, relaxation techniques and repositioning. The next pain reassessment was not documented until three hours later. RN #10 documented the patient's pain intensity was a 6; the same intensity as the patient's 8:00 p.m. assessment.

From 8:00 p.m. until 11:06 p.m., there was no evidence in the medical record, which showed the patient was reassessed to see if the non pharmacological interventions were effective at treating the patient's moderate pain.

c. Review of Patient #10's Discharge Summary, dated 3/18/19, revealed the patient was admitted on 3/16/19 after a motor vehicle accident. Patient #10 had left anterior rib fractures.

Review of the History and Physical, dated 3/16/19, revealed the physician's plan for the rib fractures included pain control.

On 3/16/19, Patient #10 was administered 10 milligrams of Oxycontin (a narcotic pain reliever) for a pain intensity of seven, which the patient reported to her nurse at 9:20 p.m. The patient's goal was two out of ten on the numeric pain scale. According to the pain assessment documented, the patient's pain was located at her left side, ribs. There was no evidence in the medical record which showed the patient was reassessed to see if the Oxycontin was effective. The next pain assessment was not documented until three hours later, at 1:31 a.m. the next day. The patient's reported pain was documented at a five, which was still not at her goal of two.

d. On 3/21/19 at 2:09 p.m., RN #5 was interviewed and stated she worked throughout the hospital. RN #5 said pain assessments were done with shift assessments. She also said patients were assessed throughout the day during hourly rounding. RN #5 said she would chart when she gave "as needed" pain medications and then conduct a follow up assessment within one hour to see if the medication was working.

RN #5 stated other interventions could be offered for pain, including: ice, heat and repositioning. She stated she would have to reassess the patient to see if the intervention was working.

RN #5 stated documentation included: the type of pain scale used; where the pain was located, if the pain radiated; and what interventions were done.

e. On 3/21/19 at 3:01 p.m., an interview was conducted with RN #7 and RN #6. RN #7 provided care to Patient #3 on 12/8/19 and 12/9/19, during the day shift.

RN #7 reviewed Patient #3's pain assessment documented by the night nurse on 12/8/18 at 8:45 p.m. RN #7 stated, the pain assessment documented was a pain level of five. RN #6 who navigated the electronic medical record during the interview, was not able to find any documented evidence which would show Patient #3's pain was addressed by nursing staff throughout the night shift beginning 12/8/18.

RN #7 stated pain management was important to promote the patient's healing and comfort. She said other interventions, in addition to medication, which could be provided to the patient were ice packs, repositioning and ambulation in the halls. She said documentation should be in the nursing notes.

f. On 3/21/19 at 4:37 p.m., an interview was conducted with Ortho/Trauma Nurse Manager (Manager) #3, Vice President of Quality & Patient Safety (VP) #4, Manager of Quality and Regulatory Compliance (Manager) #2 and Chief Nursing Officer (CNO) #1.

CNO #1 stated pain assessments were done with the morning assessment and at hourly rounding. She stated the hourly rounding assessments were documented on the whiteboard and were not part of the patient's medical record. CNO #1 stated the facility had a pain policy to address what actions were required for pain management. She stated she would refer to policy for the requirements.

Review of Patient #3's pain assessment documented on 12/8/19 at 8:45 p.m. was conducted. CNO #1 stated if the patient reported a pain level of five, she would ask the patient if he wanted medications or any other interventions. She said if there was no documentation in the medical record, the conclusion would be the patient did not want any interventions done and staff would continue to monitor.

Manager #3, who managed the unit Patient #3 and Patient #6 were admitted to, stated if a medication was administered, the assessment should be documented on the MAR. She stated if the patient was offered an option of ice, the care was assumed to be done.