HospitalInspections.org

Based on clinical record review, policy review and interview, it was determined the facility failed to ensure nursing care plans were followed related to pain assessment follow ups being performed within 30-60 minutes after pain medication was administered. The failed practice created the potential for patients to remain in pain for more than an hour with no intervention. The failed practice affected Patients #1- #5 and #8. Findings follow.

A. Review of policy titled Pain Management revealed no timeframe for a follow up for a pain assessment.

B. Nursing Care Plans stated, "Re-assess patient for main level 30-60 minutes after pain management intervention".

C. Patient #1 received PRN (as needed) pain medications on the following occasions and had no pain re-assessment within 30-60 minutes.
1) 05/19/13 at 1900, pain score of 3
2) 05/20/13 at 1208, pain score of 4
3) 05/21/13 at 1334, pain score of 7
4) 05/21/13 at 1521, pain score of 6
5) 05/22/13 at 2233, pain score of 4
6) 06/04/13 at 1325, pain score of 3

D. Patient #2 received PRN (as needed) pain medications on the following occasions and had no pain re-assessment within 30-60 minutes.
1) 05/08/13 at 1905, pain score of 3
2) 05/11/13 at 0040, pain score of 9

E. Patient #3 received PRN (as needed) pain medications on the following occasions and had no pain re-assessment within 30-60 minutes.
1) 07/29/13 at 1935, pain score of 7
2) 07/29/13 at 2254, pain score of 6
3) 07/30/13 at 0431, pain score of 4

F. Patient #4 received PRN (as needed) pain medications on the following occasions and had no pain re-assessment within 30-60 minutes.
1) 07/30/13 at 1046, pain score of 8
2) 07/30/13 at 1848, pain score of 4

G. Patient #5 received PRN (as needed) pain medications on the following occasions and had no pain re-assessment within 30-60 minutes.
1) 07/30/13 at 1519, pain score of 9
2) 07/30/13 at 1642, pain score of 8
3) 07/30/13 at 1846, pain score of 7
4) 07/31/13 at 0147, pain score of 5
5) 07/31/13 at 0620, pain score of 6

H. Patient #8 received PRN (as needed) pain medications on the following occasions and had no pain re-assessment within 30-60 minutes
1) 07/25/13 at 2141, pain score of 4
2) 07/26/13 at 1513, pain score of 8
3) 07/26/13 at 2149, pain score of 7
4) 07/27/13 at 0909, pain score of 6
5) 07/27/13 at 1531, pain score of 4
6) 07/28/13 at 0559, pain score of 6
7) 07/28/13 at 2217, pain score of 5
8) 07/29/13 at 0547, pain score of 9
9) 07/29/13 at 1005, pain score of 2
10) 07/29/13 at 1609, pain score of 9

I. Findings were confirmed by the Director of Nursing on 07/31/13 at 0900.