HospitalInspections.org

Based on interview and record review the facility failed to provide an organized nursing service when (3) three out of (5) five patients records reviewed for pain management did not include a reassessment for pain, to ensure adequate pain management. (Patients #1,3 and 4)

Findings include:


Review of Patient #1's medication administration record (MAR) reflected the patient voiced a 3/10, on a pain scale of one to ten, with 10 being the highest. Patient #1 would consider a 3 an acceptable pain level.
On 11/14/18 at 8:51 pm the patient reports a pain of 9/10 at 10:25 pm, Morphine 6 mg IV is given, there is no pain scale given.
On 11/14/19 at 11:06 pm, Dilaudid 1 mg IV is given, for a pain of 9/10, there was no reassessment of pain.
On 11/15/19:
At 12:45 am, Dilaudid 1 mg IV, for a pain of 8/10, there was no reassessment of pain.
At 2:54 pm, MS Contin 15 mg for a pain of 8/10, there was no reassessment of pain.
At 3:57 pm, Toradol 30mg was given, there was no pain assessed before and after the administration.
At 7:55 am, Dilaudid 1 mg IV was given for pain 10/10, there was no reassessment of pain.
At 9:13 am, MS Contin 15 mg was given for a pain of 7/10, there was no reassessment of pain.
At 10:31 am, Dilaudid 1 mg was given for a pain of 8/10, there was no reassessment of pain.
At 12:36 pm, Tylenol 650 mg and Toradol 30 mg was given for a pain of 7/10, there was no reassessment of pain.
At 3:19 pm, Dilaudid 1 mg was given for a pain of 9/10, there was no reassessment of pain.
At 6:12 pm, Tylenol 650 mg and Toradol 30 mg was given for a pain, there was no assessment of pain and the reassessment was reportedly an 8/10.
At 7:41 pm Dilaudid 1 mg was given for a pain of 8/10, there was no reassessment of pain.
At 9:07 pm MS Contin 15 mg was given for a pain, there was no assessment of pain and there was no reassessment for pain.
At 10:53 pm Dilaudid 1 mg was given for a pain of 8/10, there was no reassessment of pain.

Review of Patient #3's MAR reflected at 12:50 pm was given Norco, there was no pain assessment, the reassessment reflected 0/10.

Review of Patient #4's MAR reflected on 7/29/19 an administration of Dilaudid 1 mg for a pain of 10/10, there was no reassessment of pain.

Review of the facility provided policy Pain Management - Managing Pain in Adults (dated 3/1/2017) reflected," ...It is the policy of the Ascension Seton Hospitals to support the patient's right to optimal pain management ... 7. Reassess pain and patient condition to ascertain effectiveness and safety after administering an intervention based upon individual characteristics of the intervention and the clinical condition of the patient.
8. Reassess pain levels to ascertain effectiveness and safety after administering a
sedating pain medication.
1. This assessment should be based upon individual characteristics of the
medication administered and the clinical condition of the patient.
2. Recommend reassessment time intervals: Reassessment is to occur at a minimum of one hour after administration of a medication for pain or discomfort. Every 2 hours during the first 24 hours post - operatively or more frequently if necessary or as specified per provider order
3. Reassessment documentation to include patient response to the medication ...
Basic comfort measures and/or diversion modalities may be initiated without physician orders. They include but are not limited to the following:
Provide a therapeutic environment with clean, dry bedding, proper temperature, humidity, noise level, activities and rest.
Ensure proper positioning techniques (utilizing pillows, wedges, etc., as needed)
Provide backrubs and gentle massage to painful areas unless contraindicated.
Offer diversionary activities such as TV, reading, crafts, etc., according to the
patient's preferences and abilities.
Provide reassurance and empathetic listening.
Assess for spiritual needs such as prayer or meditation.
Teach relaxation techniques such as imagery, deep breathing, aromatherapy, and music, according to patient's preferences.
Encourage support of family and friends.

During an interview on the afternoon of 11/22/19, in the facility conference room, Staff #6, RN confirmed the findings.