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Based on interviews, observations, and record reviews, the facility did not ensure three patients (Patient 14, Patient 16, and Patient 25) received complete pain management care when:

1. Patient 16 was not given pain medication on 9/15/23 at 8:18 p.m. for a pain level of 7 (0 being the least and 10 being the worst) and was not given pain medication on 9/18/26 at 8:30 a.m. for a pain level of 8.

2. Patients 16 and 25 were not reassessed after pain medication was administered.

3. Patient 14 was not given pain medication on 3/8/25 at 8:28 a.m. for a pain level of 9 (with 0 being the least and 10 being the worst) and at 4:28 p.m. for a pain level of 6. Patient 14 was given pain medication on 3/8/25 at 2:06 a.m. and at 10:03 a.m. and did not have pain reassessment.

This failure resulted in inadequate pain management care for Patient 14, Patient 16, and Patient 25 which potentially affected their physical and psychosocial well-being.

Findings:

1. A review of Patient 16's History and Physical (H&P), dated 9/10/23, indicated diagnoses included paraplegia and a suprapubic catheter (a thin, flexible tube inserted directly into the bladder through a small incision in the abdomen, allowing for continuous drainage of urine). Patient 16 was hospitalized on 8/8/23 and 9/6/23 for urosepsis (a serious condition where a urinary tract infection spreads to the bloodstream). Then again, Patient 16 was admitted on 9/9/23, for abdominal pain and altered mental state. Patient 16's x-ray showed obstruction in the colon. The H&P further indicated Patient 16 did not receive continued antibiotic order when he discharged from last hospitalization. In the evening of 9/11/23, Patient 16 worsened and developed fevers. This resulted in Patient 16 to have emergency surgery.

During a review of the "Medication Administration Record" (MAR), the physician order of oxycodone (medication that acts on the central nervous system to relieve pain) had a start date 9/12/23 at 8:18 p.m., dose of 10 mg (milligrams), frequency every 4 hours PRN (as needed) for moderate pain 4-6. The "Pain Assessment" score dated 9/15/23 at 8:18 p.m. was: 7 and was given the oxycodone (a narcotic) 10 mg. Review of the record indicated Patient 16's "Pain Assessment" score dated 9/18/2023 at 0830 a.m. was: 8 and was given the oxycodone 10 mg.

During a concurrent interview and document review on 4/8/25 at 1:53 p.m. with the Nurse Manager (NM) for the Step-down unit (SDU), the NM stated Patient 16 did not have physician's order for the pain level of 7 and 8. NM said the assigned nurses should've had a conversation for action with the physician which would match Patient 16's pain level.

During a review of the hospital's policy and procedure (P&P) titled, "Pain Assessment and Management," dated 8/20/21, the P&P indicated, "Offer pain medication or interventions per physician orders based on pain scale and frequency ...Request further intervention orders if pain management is ineffective."

2. During a review of Patient 16's History and Physical (H&P), dated 9/10/23, the H&P indicated diagnoses including paraplegia and a suprapubic catheter (a thin, flexible tube inserted directly into the bladder through a small incision in the abdomen, allowing for continuous drainage of urine.) Patient 16 experienced increased abdominal pain, an altered mental state, developed fevers, and Patient 16's abdominal x-ray showed obstruction in the colon. This resulted in Patient 16 having emergency surgery.

During a record review on 4/8/25, at 1:53 p.m., with the Nurse Manager (NM) for the Step-down unit (SDU), the "Medication Administration Record" (MAR), was reviewed. The MAR included pain assessment dates 9/15/23 at 8:18 p.m., a pain score: 7 and was given oxycodone (a narcotic) 10 mg and on 9/18/23 at 8:30 a.m. pain score was: 8 and was given oxycodone 10 mg. Reassessments following the administration times of the pain medication were not documented in the MAR, Pain Assessment flow sheet or in nursing progress notes. These were requested from the facility; however facility did not provide documents that reassessments were documented in Patient 16's medical record.

During a review of Patient 25's Face Sheet, undated, indicated Patient 25 was admitted to the facility 4/6/25 with a chief complaint: suicide and diagnosis of stimulant use disorder.

During a review of the Patient 25's "Flowsheet Data", pain assessment score on 4/6/23 at 11:31 p.m. was: 5 (moderate pain). Patient 25 was administered the physician order of acetaminophen tablet 650 milligrams (mg) PRN (as needed) for moderate pain (4-6). Reassessment following the administration of pain medication was not documented within 1 hour in the MAR, Pain Assessment flow sheet or in a nursing progress note.

During an interview on 4/9/25, at 4:24 p.m., with Registered Nurse (RN) 2, RN 2 stated after giving a pain medication, the patient needs reassessment within 1 hour to evaluate if pain improves or worsens and is documented in the progress notes.

During a review of the hospital's policy and procedure (P&P) titled, "Pain Assessment and Management," dated 8/20/21, the P&P indicated, "Offer pain medication or interventions per physician orders based on pain scale and frequency ...document the reassessment of the pain score in the medical record."

3. A review of Patient 14's Face Sheet, undated, indicated Patient 14 was admitted to the facility on 3/25/25 with diagnosis of major depressive disorder.

During a concurrent interview and record review on 4/10/25, at 12:45 p.m., with Unit Manager (UM)1, the facility document "Medication Administration Report" (MAR) was reviewed. During a review of Patient 14's MAR, the physician order of acetaminophen (Tylenol - medication to treat pain) had a start date of 3/5/25 at 7:52 p.m., dose of 650 mg (milligrams), frequency every four hours PRN (as needed) for moderate pain (4-6).

During a concurrent interview and record review on 4/10/25, at 12:45 p.m., with Unit Manager (UM) 1, the facility document "Flowsheet Data" for pain assessment was reviewed. On 3/8/25 at 2:06 a.m., the flowsheet indicated Patient 14 had a pain level score of 5 (out of 10). On the MAR, the patient was given acetaminophen at 2:06 a.m.. Per Unit Manager (UM) 1, there was no pain assessment follow-up documented. On 3/8/25 at 8:28 a.m., the flowsheet indicated Patient 14 had a pain level score of 9 (out of 10). On the MAR, the patient was not given any pain medication. UM 1 stated the Mental Health Specialist (MHS - healthcare professional providing care to individuals in mental health settings) should have notified the nurse. NM 1 stated the pain level score of 9 was not addressed and there was no medication given. Per NM 1, Patient 14 did not have pain medication coverage for pain level of 7 and up.

A review of Patient 14's flowsheet on 3/8/25, at 10:03 a.m., indicated Patient 14 had a pain level score of 5 (out of 10). The MAR indicated acetaminophen was given at 10:03 a.m. Per UM 1, there was no pain assessment follow-up.

A review of Patient 14's flowsheet on 3/8/25, at 4:28 p.m., indicated Patient 14 had a pain level score of 6 (out of 10). The MAR indicated there was no pain medication given.

During a review of the facility's policy and procedure (P&P) titled, "Pain Assessment and Management," dated 8/20/21, the P&P indicated, "Offer pain medication or interventions per physician orders based on pain scale and frequency ... Document the reassessment of the pain score in the medical record."