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Based on document review and interview, facility nursing staff failed to complete required pain assessment and/or reassessment documentation for 1 of 10 patient medical records reviewed. (P1)

Findings include:

1. Facility policy titled, "Vital Signs", no policy number, publication date 2/10/2022, indicated under V. POLICY STATEMENTS: D. Pain Assessments. 3. Pain will be reassessed within 60 minutes of administration of pain management.

2. Facility policy titled, "Adult Pain Management", no policy number, publication date 08/03/2023, indicated under VI. Procedures. A. Utilize an evidence-based tool to assess pain that is consistent with patient age, condition, and ability to understand. Discuss with patient identified pain goal based on functional ability/status. Lippincott Procedures - Pain assessment. Pain assessment. Documentation. Documentation associated with pain assessment includes: initial assessment findings, reassessment findings (as indicated), date and time of the assessment, assessment tool used, pain or comfort indicators present, description of the patient's behavior, patient's activity level, changes since previous measurements, pain management interventions performed, patient's response to those interventions, progress towards pain management goals.

3. Review of P1's MR (Medical Record) indicated a physician order dated 11/2/24 at 10:44 am indicated 1 mg (milligram) IV (Intravenous) Dilaudid was ordered as needed for pain every 4 hours. At 3:15 pm on 11/2/24 MD1 ordered Oxycodone 5 mg by mouth every 4 hours as needed for moderate pain, Oxycodone 10 mg orally every 4 hours as needed for severe pain, and Compazine 5 mg IV push every six hours as needed for nausea and vomiting. On 11/3/24 at 4:47 pm 0.5 mg IV Dilaudid was ordered as needed for pain every 4 hours. Miralax 17 g (grams) to be taken orally once daily was ordered on MAR (Medication Administration Record) documentation dated 11/2/24 -11/6/24 indicated P1 received doses of each medication as needed for pain at the patient's request. P1's MR lacked documentation of nursing reassessment of pain within 60 minutes of giving medication, and response to interventions of these medication doses including but not limited to Oxycodone 5 mg given orally on 11/2/24 at 6:55 am, Oxycodone 10 mg given orally on 11/3/24 at 6:41 am, 12:17 pm, and 4:44 pm, Dilaudid 0.5 mg given IV on 11/3/24 at 6:11 pm, Oxycodone given orally on 11/3/24 at 6:32 am, and Oxycodone 10 mg given orally on 11/4/24 at 6:32 am.

4. In an interview on 12/5/24 at approximately 12:31 pm am with A2 (Accreditation & Regulatory Consultant) confirmed nursing documentation for P1 related to pain assessments, pain interventions, pain reassessments were not completed per policy, but should have.