HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #1) clinical records reviewed for nursing assessments, the Hospital failed to ensure that the registered nurse (RN) evaluated the nursing care for each patient by failing to conduct a pain reassessment after an intervention.

Findings include:

1. On 11/21/2022, the Hospital's policy titled, "Pain Management" (dated 8/2022) was reviewed and required, "... To provide a method of assessing... and reassessment guidelines for pain... III. Procedure... D. Reassessment: i... Reassessment of pain is ongoing and not simply a one-time event. Reassess after each intervention... in a timely and comprehensive manner..."

2. On 11/21/2022, the clinical record for Pt. #1 was reviewed. On 9/23/2022, Pt. #1 was admitted to the Hospital due to suicidal ideation and back pain. The clinical record indicated:

- On 9/24/2022 at 1:28 PM, an RN administered Norco (pain medication) to Pt. #1. There was no pain reassessment after the intervention.

- On 9/26/2022 at 8:31 AM and 10:47 PM, an RN administered Toradol (pain medication) to Pt. #1. There were no pain reassessments after the interventions.

3. On 9/21/2022 at approximately 11:00 AM, findings were reviewed with E #1 (Director, Center for Mental Health/Behavioral Health Unit). E #1 could not provide documentation that an RN conducted a pain reassessment after the interventions were provided to Pt. #1. E #1 said, "There should be documentation of a pain reassessment at least 30 minutes to an hour after the medication was administered."