HospitalInspections.org

Based on document review and interview, it was determined for 1 of 4 (Pt. #1) clinical records reviewed of patients admitted with pain, the Hospital failed to ensure each patient was evaluated for pain.

Findings include:

1. Hospital policy titled, "Practice Guidelines for Pain, (revised 3/11)" required, "All patients will have there pain assessed and managed when they are admitted and throughout their stay. ... The patient will be assessed at least once per shift and after every pain control modality used".

2. The clinical record of Pt. #1 included that Pt. #1 was 46 year old female admitted on 1/21/13 for Intractable Headache. The medication administration record dated 1/21/13 included that Norco (a narcotic pain reliever) was administered at 5:20 PM with out a pain assessment documented before or after pain medication administration.

3. The admitting RN (E#4) was interviewed on 5/2/13 at 1:00 PM. E#4 stated that she remembers Pt. #1 coming to the hospital with a headache, but remembers nausea as being the primary focus. When asked about whether the pain scale was used to assess Pt. #1 ' s pain, E#4 stated, " I did not have the patient rate her pain " .

4. During an interview on 5/2/13 at 3:00 PM, The Chief Nursing Officer agreed that she could not find documentation of the pain scale being used to assess Pt. #1 for medication administration or on admission.

Based on document review and interview, it was determined for 1 of 4 (Pt. #1) clinical records reviewed of patients admitted with pain, the Hospital failed to ensure each patient was evaluated for pain.

Findings include:

1. Hospital policy titled, "Practice Guidelines for Pain, (revised 3/11)" required, "All patients will have there pain assessed and managed when they are admitted and throughout their stay. ... The patient will be assessed at least once per shift and after every pain control modality used".

2. The clinical record of Pt. #1 included that Pt. #1 was 46 year old female admitted on 1/21/13 for Intractable Headache. The medication administration record dated 1/21/13 included that Norco (a narcotic pain reliever) was administered at 5:20 PM with out a pain assessment documented before or after pain medication administration.

3. The admitting RN (E#4) was interviewed on 5/2/13 at 1:00 PM. E#4 stated that she remembers Pt. #1 coming to the hospital with a headache, but remembers nausea as being the primary focus. When asked about whether the pain scale was used to assess Pt. #1 ' s pain, E#4 stated, " I did not have the patient rate her pain " .

4. During an interview on 5/2/13 at 3:00 PM, The Chief Nursing Officer agreed that she could not find documentation of the pain scale being used to assess Pt. #1 for medication administration or on admission.