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Based on record review and interview, the CAH failed to administer prn pain medication by accepted standards of practice as evidenced by failing to perform a pain assessment after administering a PRN pain medication for 1 of 1 patient (Patient #13) reviewed for pain medication administration. Findings:

Review of the CAH's policy for Pain Management revealed in part, "The frequency of pain reassessment shall be dictated by the patient's pain status, risk factors for adverse events caused by treatment and effectiveness of pain relief interventions. Document effectiveness/ineffectiveness of as reported by the patient. If ineffective document further interventions and follow-up with physician and patient response."

Patient #13
Patient #13 was admitted to the hospital with an observation level on 11/26/19 with a diagnosis of Post-Operative pain.

Review of the physician orders dated 11/26/19 and timed 10:37 p.m. for Patient #13 revealed, Diagnosis: Post- operative Pain, Morphine 4 mg/ml inj 4 mg IVP prn q 4 hour for severe pain. Review of physician orders for 11/27/19 at 9:27 a.m. revealed Percocet (oxycodone/APAP 10/325 mg) tab 1 tablet po prn q 4 hours for moderate pain.

Review of the Medication Administration Record for Patient #13 revealed the patient was assessed as having a pain score of 10/10 on 11/27/19 at 4:54 a.m. Morphine 4 mg was administered at 5:27 a.m. to the patient. There was no documentation of a reassessment of the pain response to the pain medication given at 5:27 a.m. At 7:32 a.m. on 11/27/19, the patient complained of pain and the patient's pain was scored at a 10/10. At 10:13 a.m. on 11/27/19 the patient was administered Morphine 4 mg and there was no documentation the pain was assessed after the administration of the Morphine. At 12:26 p.m the patient reported a pain score of 10/10. Percocet (Oxycodone/APAP 10/325 mg) was administered. There was no documentation the patient's pain response was reassessed; the patient was discharged home at 12:58 p.m. on 11/27/19.

An interview was conducted with S2CNO on 1/14/19 at 2:30 p.m. She stated with review of Patient #13's medical record, she confirmed the above findings. S2CNO confirmed the nurses were not documenting the patient's response to the prn pain medication.