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A. Based on document review and interview, it was determined that for 1 of 5 patients' (Pt. #1) clinical records reviewed for nursing pain assessments, the Hospital failed to ensure that the registered nurse (RN) evaluated the nursing care for each patient by failing to conduct a pain reassessment after an intervention, as required.

Findings include:

1. On 11/30/2022, the Hospital's policy titled, "Pain Management" (effective 2/2022) was reviewed and required, "... to provide patients with a collaborative approach to effective pain management... V. Procedure... I. Reassessment of pain and documentation are two separate functions. Reassessment of pain is ongoing and not simply a one-time event. Reassess after each intervention... 1...b. Within an hour after pharmaceutical intervention..."

2. On 11/30/2022, the clinical record for Pt. #1 was reviewed. On 2/12/2022, Pt. #1 was admitted to the Hospital due to a fall. The clinical record indicated:

- On 2/27/2022 at 12:00 MN, Pt. #1's pain score was 6 (goal was 0). Norco (pain medication) was given at 12:19 AM. A pain reassessment was conducted at 8:00 AM (8 hours after the intervention).
- On 3/1/2022 at 8:33 PM, Pt. #1's pain score was 6 (goal of no pain). Pt. #1 was given Norco at 8:33 PM. A pain reassessment was conducted at 12:00 MN (3 ½ hours later).

3. On 11/30/2022 at approximately 3:10 PM, an interview was conducted with E #1 (Unit Manager, NCCU/Neurology Critical Care Unit). E #1 stated that pain reassessment should be conducted at least one hour after each intervention.

4. On 11/30/2022 at approximately 11:00 AM, findings were discussed with E #20 (RN Informatics/Computer Navigator). E #20 stated that the clinical record indicated that pain reassessment was conducted several hours after the intervention was provided.

B. Based on document review and interview, it was determined that for 1 of 5 (Pt. #1) clinical records reviewed, the Hospital failed to ensure that the registered nurse supervised and evaluated the nursing care for each patient by failing to document provision of patient's nutritional needs.

Findings include:

1. On 11/30/2022, the Hospital's job description for registered nurse (NCCU and 10 Tower) (effective 1/2022) was reviewed and required, "... The registered nurse is responsible for providing and coordinating comprehensive patient care..."

2. On 11/30/2022, the Hospital's policy titled, "Nursing Documentation" (effective 11/2022) was reviewed and required, "The purpose of this policy is to set forth the requirements for or nursing documentation in the patient's electronic health record... IV... C. Nursing team members are responsible for the timely documentation of all aspects of nursing care provided to the patient..."

3. On 11/30/2022, the clinical record for Pt. #1 was reviewed. On 2/12/2022, Pt. #1 was admitted to the Hospital due to a fall. From 3/15/2022 through 3/18/2022, the clinical record included a physician's order for Pt. #1 to be given a nutritional supplement three times a day with meals (breakfast, lunch, and dinner). The clinical record lacked documentation that Pt. #1 was given nutritional supplements on 3/15/2022, dinner; 3/16/2022, breakfast, lunch, and dinner; 3/17/2022, breakfast, lunch, and dinner; and 3/18/2022, breakfast.

4. On 11/30/2022 at approximately 3:10 PM, an interview was conducted with E #15 (Interim Manager, 10T). E #15 stated that nurses are responsible for making sure that physician's orders are followed. E #15 stated that documentation regarding nutrition is documented by nursing.

5. On 11/30/2022 at approximately 11:00 AM, findings were discussed with E #20 (RN Informatics/Computer Navigator). E #20 could not provide documentation to indicate that nutritional supplements were given on 3/15/2022, 3/16/2022, 3/17/2022, and 3/18/2022.

C. Based on document review and interview, it was determined that for 1 of 5 (Pt. #1) clinical records reviewed, the Hospital failed to ensure that the registered nurse evaluated the nursing care for each patient by failing to document provision of patient's needs regarding use of incentive spirometer (breathing exercise device).

1. On 11/30/2022, the Hospital's job description for registered nurse (NCCU and 10 Tower) (effective 1/2022) was reviewed and required, "... The registered nurse is responsible for providing and coordinating comprehensive patient care..."

2. On 11/30/2022, the Hospital's policy titled, "Nursing Documentation" (effective 11/2022) was reviewed and required, "The purpose of this policy is to set forth the requirements for or nursing documentation in the patient's electronic health record... IV... C. Nursing team members are responsible for the timely documentation of all aspects of nursing care provided to the patient..."

3. On 11/30/2022, the clinical record for Pt. #1 was reviewed. On 2/12/2022, Pt. #1 was admitted to the Hospital due to a fall. On 3/11/2022, a provider's order for nurses to encourage Pt. #1 to use incentive spirometer (breathing exercise device used for post-surgical patients) every hour while awake from 3/11/2022 through 3/22/2022. The clinical record lacked documentation that Pt. #1 was encouraged use of incentive spirometer on 3/13/2022 and 3/15/2022.

4. On 11/30/2022 at approximately 3:10 PM, an interview was conducted with E #15 (Interim Manager, 10T). E #15 stated that nurses are responsible for making sure that physician's orders are followed.

5. On 11/30/2022 at approximately 11:00 AM, findings were discussed with E #20 (RN Informatics/Computer Navigator). E #20 could not provide documentation to indicate that nurses encouraged use of incentive spirometer on 3/13/2022 and 3/15/2022.