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Based on staff interview, review of facility policies and procedures, and review of one of 10 medical records (#1), it was determined the facility failed to ensure that patients receive pain assessments after pain management interventions are implemented.

Findings include:

Reference #1: Facility policy titled, "Patient Rights and Responsibilities," last reviewed 10/2021 states, " ... These rights shall include at least the following ... 31. To expect and receive appropriate assessment, management, and treatment of pain as an integral component of that person's care, in accordance with N.J.A.C. 8:43E-6."

Reference #2: Facility policy titled, "Pain Assessment and Management," last reviewed 02/2023 states, "The registered nurse (RN) is responsible for assessing the patient for pain in order to support and facilitate activities and resources that address the patient's pain in a safe manner. ... Patients will be screened by the RN for the absence and/or presence of pain as a part of their initial evaluation and on an ongoing basis. ... Admission, transfer, once per shift, if there is a change in the patient's condition, pre and post pain management intervention ... ."

Review of Medical Record #1 on 03/01/23, in the presence of Staff #24 (Assistant Director of Nursing, Informatics), revealed the following:

A physician's note, dated 11/23/22, indicated that the patient reported severe pain to his/her right flank, rated 9 out of 10 on a 0 to 10 pain scale. STAT (immediate)Dilaudid 0.5 mg (milligrams) was ordered by the physician for pain at 11:00 AM and administered to the patient by the RN at 11:15 AM. There was no evidence in the medical record that a pain assessment was performed by the RN after Dilaudid was administered.

A physician's note, dated 11/24/22, stated, "called to bedside by RN due to 'inconsolable pain.' Patient found writhing in pain in bed. Endorses 10/10 (10 out of 10) right flank pain." Documentation in the medical record indicated the patient received Dilaudid 0.5 mg via IV (intravenously) at 12:34 PM and was not due to receive the next dose of Dilaudid until 3:34 PM. The physician ordered a dose of STAT (immediate) Dilaudid 0.5 mg at 2:15 PM. The RN administered Dilaudid 0.5 mg at 2:21 PM. There was no evidence in the medical record that a pain assessment was performed by the RN after the pain medication was administered, in accordance with facility policy.

On 03/01/23 at 2:45 PM, Staff #24 confirmed that there was no evidence of pain assessments performed by the RN after the administration of Dilaudid on 11/23/22 and 11/24/22.

Based on staff interviews, review of facility policy and procedure, and review of facility documents, it was determined the facility failed to respond to a formal grievance by sending an acknowledgement letter to the complainant within seven business days, in accordance with facility policy.

Findings include:

Reference: Facility policy titled, "Patient Complaint and Grievance," last reviewed 03/2022 states, " ... Investigation, appropriate action, and response are to be completed as soon as possible. ... An acknowledgement letter is sent to the complainant within 7 business days. The acknowledgement letter sent to the complainant will explain that the grievance is being investigated and that they will receive a final written response within 30 business days. ... ."

On 03/01/23, a review of the "Facility Grievance Log" confirmed that a formal grievance was filed with the facility on behalf of Patient #1 on 11/29/22. The "Facility Grievance Log" indicated that an Acknowledgement of Grievance Letter was sent to the complainant on 02/21/23, 85 days after the grievance was first received by the facility. On 03/01/23 at 3:00 PM, Staff #3 confirmed the complainant's Acknowledgement of Grievance Letter was not sent to the complainant within seven business days, as indicated in the facility's policy.