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Based on document review and interview nursing services failed to document patient pain location, failed to implement interventions for pain, and/or failed to complete pain intervention reassessment for 4 of 10 medical records (MRs) reviewed (P1, P5, P6, and P7).


Findings include:

1. Review of policy/procedure titled, "Mother & Child: Epidural & Intrathecal Analgesia," Publication date 02/27/2024, indicates the following:
Under I. Purpose:
A. All patients have the right to appropriate assessment and management of pain as appropriate to the patient's condition.
VI. Procedure:
a. RN must continually assess the patient for pain, any type of pain. If the patient is experiencing pain, the RN should contact the Obstetric Anesthesia Services Provider who performed the procedure or his/her partner covering call to receive orders for pain management.
d. Monitor for the following parameters:
vi. Pain score

2. Review of policy/procedure titled, "Adult Pain Management," Publication date 08/03/2023; indicates the following:
Under I. Purpose:
All patients have the right to appropriate assessment and management of pain.
VI. Procedure:
B. Establish realistic pain goals based on functional ability/status.
If it is anticipated that the patient will have pain with an activity pharmacologic intervention is appropriate even if the patient is at or below the identified comfort-function goal.
C. Reassess and respond to the patient's pain plan throughout the RN's shift.
If current pain management plan not effective, consider implementation of additional interventions if appropriate or contact patient's provider.

3. MR review for P1 indicated they had placement of an epidural. MR review of pain assessment using pain scale of 0 - 10, indicated on 10/20/24 at 4:45 p.m., P1 rated their pain at 3, intervention included breathing techniques, pain goal was 3, P1 did not have follow up pain assessment completed. On 10/20/24 at 7:30 p.m., P1 rated their pain at 2, intervention included breathing techniques, pain goal was 3, P1 did not have follow up pain assessment completed. On 10/20/24 at 10:00 p.m., P1 rated the pain in their abdomen at 5, intervention included breathing techniques, P1 did not have follow up pain assessment completed. On 10/21/24 at 4:45 a.m., P1 rated the pain in their head at 3, intervention included medication, P1 did not have follow up pain assessment completed. On 10/21/24 at 1:00 p.m., P1 rated the pain in their abdomen at 3, intervention included medication, pain goal was 3, P1 did not have follow up pain assessment completed. On 10/21/24 at 7:30 p.m., P1 rated their pain at 4, documentation lacked pain location, did not receive any pain interventions, did not have a pain goal, and did not have follow up pain assessment completed. On 10/22/24 at 4:48 a.m., P1 rated their pain at 7, intervention included medication, documentation lacked pain location, P1 did not have follow up pain assessment completed.

4. MR review for P5 indicated they had placement of an epidural. MR review of pain assessment using pain scale of 0 - 10, indicated on 10/25/24 at 2:49 p.m., P5 rated their pain at 4 and did not have follow up pain assessment completed. On 10/25/24 at 4:00 p.m., P5 rated their pain at 3, did not have any pain interventions, and did not have follow up pain assessment completed. On 10/26/24 at 2 a.m., P5 rated the pain in their back and abdomen at 10, interventions included pain medication, breathing techniques, massage, reposition and significant other, P5 did not have any pain assessment follow up. On 10/26/24 at 4 a.m., P5 rated the pain in their back and abdomen at 6, interventions included breathing techniques, massage, reposition and significant other, P5 did not have any pain assessment follow up. On 10/26/24 at 5:30 a.m., P5 rated the pain in their back and abdomen at 6 interventions included breathing techniques, massage, reposition and significant other, P5 did not have any pain assessment follow up. On 10/26/24 at 9:04 a.m., P5 rated the pain in their perineum at 6, interventions included breathing techniques, reposition and emotional support, P5 did not have follow up pain assessment completed. On 10/27/24 at 8:20 a.m., P5 rated their pain at 2, did not have any pain interventions, and did not have follow up pain assessment completed.

5. MR review for P6 indicated they had placement of a spinal block. MR review of pain assessment using pain scale of 0 - 10, indicated on 10/31/24 at 11:26 a.m., P6 rated their pain at 5, documentation lacked location of pain, and intervention included pain medication. On 11/01/24 at 2:55 a.m., P6 rated their pain at 5, documentation lacked location of pain, intervention included pain medication, P6 did not have follow up pain assessment completed. On 11/02/24 at 1:03 a.m., P6 did not have a pain rating, documentation lacked location of pain, intervention included pain medication, and did not have follow up pain assessment completed. On 11/02/24 at 9:29 a.m., P6 rated their pain at 7, documentation lacked location of pain, intervention included pain medication, P6 did not have follow up pain assessment completed.

6. MR review for P7 indicated they had placement of a spinal block. MR review of pain assessment using pain scale of 0 - 10, indicated on 10/30/24 at 8:11 a.m., P7 rated the pain in their back at 5, interventions included breathing techniques and reposition, P7 did not have follow up pain assessment completed. On 10/30/24 at 10:00 a.m., P7 rated the pain in their back at 6, interventions included breathing techniques, reposition, emotional support, and significant other, P7 did not have a follow up pain assessment completed. On 10/30/24 at 7:40 p.m., P7 did not have a pain rating for pain in their abdomen, intervention included splinting, and did not have a follow up pain assessment completed. On 10/31/24 at 5:30 a.m., P7 rated the pain in their surgical incision at 4, intervention included medication, their pain goal was 2, and did not have follow pain assessment completed. On 10/31/24 at 9:45 a.m., P7 rated the pain in their surgical incision at 2, intervention included medication, their pain goal was 2, and did not have follow pain assessment completed.

7. Interview with A4 on 04/16/25 at approximately 4:15 p.m., confirmed P1, P5, P6, and P7 were missing pain reassessments which include pain location and intervention provided.