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Based on hospital policy review, medical record review, and administrative staff interview, hospital nursing staff failed to supervise and evaluate patient care, by failing to reassess pain following the administration of pain medications, in 2 of 3 patients (Patients #5 and #1), per hospital policy.

The findings include:

Review of hospital policy titled, "Pain Management", current effective dates: 05/08/2015 and 12/05/2016, revealed, "...A reassessment for the presence and intensity of pain is performed... c. Following any interventions intended to reduce the patient's pain (example administration of pain medications... Reassessments take place within a clinically appropriate interval not to exceed 2 hours following an intervention... "

1. Review of the open medical record of Patient #1 revealed a 41 year old female admitted on 11/29/2016 with abdominal pain. Dilaudid (a pain medication) was administered on 12/03/2016 at 1037, with no evidence of reassessment of the pain intervention by 12/03/2016 at 1237 (2 hours after administration of the pain management intervention). Review revealed Codeine (a pain medication) was administered on 12/06/2016 at 1751, with no evidence of reassessment of the pain intervention by 12/06/2016 at 1951 (2 hours after administration of the pain management intervention). Review revealed Fioricet (a pain medication) was administered on 12/08/2016 at 0433, and a reassessment of, "Effectiveness: Mild relief obtained" was performed on 12/08/2016 at 0922 (4 hours 49 minutes after administration of the pain management intervention).

Interview conducted on 12/08/2016 at 0930, with Administrative Staff #1 revealed hospital policy was not followed in regards to reassessment after the administration of a pain management intervention


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2. Review of closed medical record of Patient #5 revealed a 40 year old female admitted on 10/28/2016 with abdominal pain. Dilaudid was administered on 11/02/2016 at 0232 with reassessment at 0603 (3 hrs and 31 minutes later); 11/02/2016 at 0624 with reassessment at 1022 (3 hrs and 58 minutes later); 11/02/2016 at 2224 with reassessment at 0055 on 11/03/2016 (2 hrs and 31 minutes later); and 11/03/2016 at 0237 with reassessment at 0620 (3 hrs and 43 minutes later).

Interview conducted on 12/08/2016 at 0930 with Administrative Staff #1 revealed hospital policy was not followed in regards to reassessment after the administration of a pain management intervention.

NC00122262