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Based on clinical record review, policy and procedure review and interview, it was determined, of the 10 Emergency Room records reviewed, there was no evidence 3 of 3 (#7-#9) patients who received pain medication were reassessed after the administration of pain medication. The failed practice did not ensure the patient's pain level was at an acceptable range for the patient. The failed practice had the potential to affect all patients receiving pain medications. The findings follow:

A. Review of Patient #7's clinical record on 04/19/17 revealed the patient received Morphine 2 mg (milligrams) IV (intravenous) Push on 04/17/17 at 1207, 1305 and 1505. There was no evidence the patient's pain was reassessed after Morphine was administered for any of the times of administration. The findings were confirmed in an interview with the Registered Nurse Manager of the Emergency Department on 04/19/17 at 1450.
B. Review of Patient #8's clinical record on 04/19/17 revealed the patient received Hydromorphone 1 mg IV Push on 04/15/17 at 2314. There was no evidence the patient's pain was reassessed after Hydromorphone was administered. The findings were confirmed in an interview with the Registered Nurse Manager of the Emergency Department on 04/19/17 at 1500.
C. Review of Patient #9's clinical record on 04/19/17 revealed the patient received Morphine 4 mg IV Push on 04/14/17 at 2203. There was no evidence the patient's pain was reassessed after Morphine was administered. The findings were confirmed in an interview with the Registered Nurse Manager of the Emergency Department on 04/19/17 at 1505.
D. Review of the policy "Pain Management" on 04/19/17 revealed, "III. Reassessments: 2. With pharmacologic or non-pharmacologic intervention. a. Post pharmacologic intervention the patient should be reassessed within one (1) hour of the administration of intramuscular or IV pain medications, and within two (2) hours for the administration of oral medications."
E. The findings of D were confirmed in an interview with the Chief Quality Officer on 04/19/17 at 1520.