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Based on record review, interview and review of the policy and procedure it was determined the nurse failed to ensure pain levels were reassessed after the administration of pain medication per the policy and procedure. This affected two of two patients, Patient #6 and #11. A total of 20 medical records were reviewed. The patient census was 153.

Findings include:

Review of the policy and procedure titled "Pain Management", approval date: 03/13/19, next review: 03/13/21, revision 10, policy start date: 12/11/15 revealed the purpose is to provide pain management that reduces suffering from preventable pain. The policy is including pain that is assessed using an applicable standardized pain scale. Pain is subjective and the patient's self-reported pain level is the most reliable indicator. Further review of the policy included the patient's right and responsibilities and the patient has the right to appropriate assessment and management of pain. The goals of the multidisciplinary team is to assess/re-assess pain consistently. The procedure for pain reassessments is documented within 60 minutes.

1. Review of the medical record for Patient #6 on 05/14/19 revealed he/she arrived to the emergency room on 05/09/18 with weakness of both lower extremities. On 05/10/19 Patient #1 had a laminectomy of the lumbar area. (surgical procedure on the lower spine) The post anesthesia note was dated 05/10/19 at 10:39 PM.

On 05/10/19 at 1:30 PM two Percocet 5/325 (5 mg oxycodone and 325 mg acetaminophen) for pain were given by Staff H for a pain level of eight out of 10 with 10 being the highest level of pain. There was no documented evidence of a follow up pain reassessment.

On 05/10/19 at 6:40 PM Staff H gave Patient #6 two Percocet for a pain level of seven out of 10. There was no documented evidence of a follow up pain assessment.

On 05/11/19 at 8:49 PM Staff I gave one Percocet to Patient #6 for a pain level of six. There was no documented evidence that Staff I reassessed the patient's pain level.

On 05/12/19 at 1:31 PM two Percocet was given for a pain level of six. There was no documented evidence of a pain reassessment until 05/12/19 at 3:18 PM at which time the pain level was a five.

On 05/13/19 at 9:24 AM Patient #6 complained of back pain and rated the pain a six. Staff H gave two Percocet and there was no documented evidence of a follow up pain reassessment. At 5:13 PM the patient complained of back pain and rated the pain a level five. Staff H gave the patient two Percocet and there was no documented evidence of a pain reassessment.

This finding was confirmed with Staff J on 05/13/19 at 2:55 PM.

2. Review of the medical record for Patient #11 on 05/14/19 revealed the patient came to the emergency room on 05/10/19 due to a fall. The patient was admitted on 05/10/19 and had right hip surgery on 05/11/19.

On 05/10/19 at 9:23 PM the patient was given Tylenol 650 milligrams for right hip pain. The pain level was an eight out of 10 with 10 being the highest. The was no documented evidence the nurse reassessed the patients pain.

This finding was confirmed with Staff J on 05/14/19 at 10:00 AM.