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Based on review of the facility's policy and procedures, medical record, and staff interview it was determined the facility failed to ensure a registered nurse supervised and evaluated the administration and effectiveness of pain medication for one (#2) of three patients sampled. This practice does not ensure patient goals for pain control are maintained.

Findings:

Review of the facility's policy, "Pain Assessment, Reassessment and Management of PCA", last revised 2/08, requires that any patient care provider, from any department, that has implemented a pain control mechanism shall reassess the patient to determine amount of pain control or relief achieved. The time of reassessment will vary depending on the type and route of the pain control mechanism. Recommended times for pain reassessment are as follows: pain control mechanism given intravenously should be within 15 minutes, pain control mechanism given intramuscular should be within 30 minutes, and pain control mechanism given by mouth should be within 1 hour.

Patient #2 had a surgical repair of a hip fracture on 5/03/10. Physician order on 5/03/10 instructed for Morphine 4-6 milligrams (mg) IM (Intramuscularly) every 3 hours as needed for severe pain (7-10 on pain scale) and Vicodin 1-2 tablets every 3 hours as needed for moderate pain (3-6 on pain scale).

Review of nursing documentation noted on several occasions the patient was medicated for pain and not reassessed for relief of pain. On 5/05/10 at 4:45 a.m. the patient's pain level was 8 of 10 on a scale of 1 to 10 with 10 being the worst pain. Review of the MAR (Medication Administration Record) revealed the patient was medicated with Morphine at 4:45 a.m. There was no documentation of reassessment. Physician order dated 5/05/10 was for Morphine 1-2 mg IV (intravenously) every 3 hours as needed. On 5/05/10 at 5:00 p.m. the patient was medicated with Morphine 1 mg IV at 5:00 p.m. There was no documentation of a pain assessment or reassessment. On 5/06/10 at 6:00 a.m. the patient was assessed to have pain of 7 of 10 and was medicated with Morphine 1 mg IV at 6:00 a.m. There was no documentation of reassessment for effectiveness. On 5/06/10 at 11:15 a.m. the patient was medicated with Morphine 1 mg for pain as evidenced by groaning. There was no reassessment for effectiveness documented.

Interview with the Chief Nursing Officer on 6/03/10 at 3:15 p.m. confirmed the above findings.