HospitalInspections.org

Based on policy review, medical record review, document review, and interview, in 1 of 15 medical records reviewed (Patient #1), nursing staff failed to adhere to the policies and procedures of the hospital. The facility failed to ensure that a pain reassessment was performed and documented within 60 minutes of receiving an as needed (PRN) pain medication.

Findings include:

Review of the policy titled "Pain Management Procedure", dated October 2023, indicated "Complete reassessments will be completed within 60 minutes of administering as needed (PRN) pain medications." "If pain is present, identify that it is "ongoing" pain and document; Location of pain; Orientation of pain (i.e. left, right, mid); Type of pain (i.e. aching, throbbing, stabbing); Is it acceptable to the patient (yes/no); Interventions used if needed."

Review of the policy titled "RRH Nursing Documentation Guidelines Policy", dated August 2023, revealed patient pain level and "reassessment/observation" will be documented following PRN pain medication administration.

Review on 01/23/25 of the medical record for Patient #1 revealed from 05/11/24 to 05/26/24, for 35 of 87 opportunities nursing staff failed to document a complete pain reassessment within 60 minutes after receiving a PRN dose of pain medication.

Interview on 01/24/25 at 11:00 AM with Staff (C), Clinical Nurse Specialist, stated the expectation per policy is that a pain reassessment should be documented within 60 minutes of a patient receiving a PRN pain medication.