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Based on interview and record review the facility failed to follow its policy and procedure (P&P) titled, "Pain management, assessment, and reassessment", when nursing staff failed to complete a pain reassessment after administering a PRN (as needed) pain medication for three of 30 sampled patients (Patient 7, Patient 8 & Patient 10). This failure resulted in nursing staff being unaware of pain medication effectiveness administered to Patient 7, Patient 8 & Patient 10, and had a potential for Patient 7, Patient 8 & Patient 10 to continue to be in pain.

Findings:

During a review of Patient 7's Medication order, dated 3/3/25, order indicated Dilaudid (controlled drug used for moderate to severe pain) Q4H PRN (every 4 hours as needed).

During a review of Patient 7's Medication Administration Record (MAR) dated, 3/3/25, MAR indicated, Patient 7 was given Dilaudid at 1428 (2:28p.m.).

During a review of Patient 7's Assessments dated, 3/3/25, Assessments indicated, a pain reassessment was not completed until 1951 (7:51 p.m., over 4 hours after pain medication was administered at 1428).

During an interview on 3/4/24, at 2:20 p.m., with Director of Patient Safety (DPS), DPS stated, there is no charted pain assessment for Patient 7 after administration at 1428, until 1951.

During a review of Patient 8's Medication order dated 3/2/25, order indicated, Dilaudid Q4H PRN.

During a review of Patient 8's MAR dated 3/2/25, MAR indicated, Patient 8 was given Dilaudid at 1255.

During a review of Patient 8's Assessments dated 3/2/25, Assessments indicated, a pain reassessment was not completed until 1600 (4p.m., 3 hours after administration).

During an interview on 3/4/25, at 2:32 p.m., with DPS, DPS stated, Patient 8 was reassessed for pain at 1600, after the 1255 administration of Dilaudid.

During a review of Patient 10's Medication order dated 2/23/25, order indicated Norco (controlled drug used for moderate to severe pain) Q4H PRN.

During a review of Patient 10's MAR dated 3/2/25, MAR indicated, Patient 10 received Norco at 1354 (1:54p.m.).

During a review of Patient 10's Assessments dated 3/2/25, Assessments indicated, Patient 10 was not reassessed for pain until 1800, after the 1354 administration of Norco (4 hours later).

During an interview on 3/4/25, at 2:47 p.m., with DPS, DPS stated, Patient 10 was reassessed for pain after the 1354 administration at 1800.

During a review of the facility's P&P titled, "Pain management, assessment, and reassessment", dated 2024, the P&P indicated, "Pain Reassessment B. A reassessment for the presence of pain shall be performed at least once a shift, with each initiation of pain management therapy, after administration of pain medication. . .2. Reassessments shall take place within one (1) hour following an intervention and be documented appropriately".

Based on interview and record review, the facility failed to have a procedure in place to ensure accuracy of prescription medication orders in the Emergency Department, for one of 30 sampled patients (Patient 1). This failure resulted in the incorrect medication to be ordered for Patient 1, with incorrect instructions for use, resulting in a delay of Patient 1's treatment.

Findings:

During a review of Patient 1's Emergency Provider Note, dated 10/31/24, Note indicated, "[Patient 1] presents to the emergency department for right eyelid swelling and yellowish discharge which started yesterday evening. . . Patient seen for eye discomfort most likely early stye. I will write her for tobramycin ointment [antibiotic ointment for use in eyes]. . .Current Visit scripts Gentamicin (Gentamicin Topical Oint) [antibiotic ointment for skin use] 1 applic [application] topical BID [twice daily]".
During a review of Patient 1's printed prescription dated 10/31/24, prescription indicated, "Gentamicin 0.1% ointment Trade name: Gentamicin Topical oint. . .1 applic topical BID stye, no refills use on upper eyelid & in eye". Signed by Physician Assistant A (PA A).

During a review of Medline Plus (medical encyclopedia from the National Library of Medicine, part of the National Institute of Health) page for medication Gentamicin Topical, encyclopedia indicated, "Topical gentamicin comes as a cream and ointment to apply to the skin. . .Topical gentamicin is only for use on the skin. Be careful not to get the medication in your eyes".

During an interview on 2/28/25, at 12:45 p.m., with Patient 1, Patient 1 stated, she received a printed prescription from the emergency department on 10/31/24 early in the morning. Patient 1 stated, she took the prescription to a local pharmacy and the pharmacist stated, the prescription was written for a medication that cannot go in the eye, and the instruction states place in eye. Patient 1 stated she was unable to fill the prescription as the facility was not available via phone to correct the prescription error while at the pharmacy.

During a review of Patient 10's Emergency provider report dated 10/31/25, at 2125 (9:25 p.m.) report indicated, "Patient states she seen [sic] here earlier today but unable to pick up her prescriptions at the pharmacy given the pharmacist said the medication was for skin, not eyes, and her eye swelling has gotten worse so that is why she is back here today. . .Patient was advised of supportive care measures and given a prescription for erythromycin ointment which is an ophthalmic solution [liquid eye drops] and should be accepted by any pharmacy. . .Active scripts Erythromycin (Romycin opth oint [ophthalmic ointment: antibiotic] 0.5%)"
During an interview request on 3/4/25-3/6/25, PA A declined to be available for an interview.

During an interview on 3/4/25, at 10:51 a.m., with Director of Pharmacy (DOP), DOP stated, the facility does not monitor prescriptions that are sent out in the emergency department.

During an interview on 3/6/25, at 4:41 p.m., with DOP, DOP stated, Gentamicin ointment should not be applied in the eyes.