HospitalInspections.org

Based on document review and interview, nursing services failed to ensure patient pain level assessments/reassessments were completed per facility policy for 1 of 10 medical records reviewed. (Patient #1)

Findings include:

1. Facility policy titled "PAIN ASSESSMENT AND MANAGEMENT" Policy Number 26.2.035F, last revised on 3/3/25 indicated the following: "POLICY/PURPOSE: To assure that all patients are in an environment that appropriately assesses pain and provides adequate treatment strategies, assesses the effectiveness of the treatment. II. IPU (Inpatient Unit)/PUC (Psychiatric Urgent Care): c: If pain is rated greater than or equal to a six (6) at any point during admission, nursing staff will offer prescribed over the counter as needed medication. i. The pain rating will be documented on the Medication Administration Record (MAR) in the electronic medical record. ii. Sixty (60) minutes after the medication administration, nursing staff will follow up with client regarding level of pain rating after intervention. This will be documented in the MAR as a follow up item. iii. Pain that remains at a 6 or greater, then alternative as needed over the counter medication can be offered and/or LP (Licensed Practitioner) guidance for ongoing pain management may occur. 1. Documentation of the follow up plan will be documented by the nurse in the MAR as above. 2. Any change in the pain management plan will be documented, with rationale, by the LP in the daily rounding note.

2. Review of patient #1's medical record indicated the following:
The patient was admitted on 2/11/25 at 1:00 p.m. and currently inpatient at the facility. The patient had a diagnosis that included, but was not limited to, schizoaffective disorder, bipolar type and tooth pain.

(A.) A physician order for Hydrocodone/Acetaminophen 7.5-325 milligrams 1 tablet by mouth at bedtime as needed with a start date of 2/13/25 and end date of 2/16/25.

A physician order for Ibuprofen 200 milligrams 4 tablets by mouth every eight hours with a start date of 2/13/25 and end date of 3/12/25.

A physician order for Acetaminophen 500 milligrams 2 tablets by mouth every eight hours as needed with a start date of 2/12/25 and end date of 3/11/25.

(B.) A review of Patient #1's Medication Administration Record indicated medications for pain were administered that included but were not limited to the following:

On 2/14/25 at 12:51 p.m. and 9:47 p.m., Ibuprofen 200 milligrams 4 tablets by mouth. The medical record lacked documentation of a pain level assessment prior to pain intervention, a reassessment 60 minutes after a pain intervention at 1:51 p.m. and 10:47 p.m. and/or patient refusal of pain level assessments/reassessments.

On 2/15/25 at 9:51 p.m., Hydrocodone/Acetaminophen 7.5/325 milligrams 1 tablet by mouth for pain. The medical record lacked documentation of a pain level assessment prior to pain intervention, a reassessment 60 minutes after a pain intervention at 10:51 p.m. and/or patient refusal of pain level assessments/reassessments.

On 2/17/25 at 12:35 p.m. and 10:03 p.m., Ibuprofen 200 milligrams 4 tablets by mouth. The medical record lacked documentation of a pain level assessment prior to pain intervention, a reassessment 60 minutes after a pain intervention at 1:35 p.m. and 11:03 p.m. and/or patient refusal of pain level assessments/reassessments.

On 2/20/25 at 12:08 p.m. and 8:29 p.m., Ibuprofen 200 milligrams 4 tablets by mouth. The medical record lacked documentation of a pain level assessment prior to pain intervention, a reassessment 60 minutes after a pain intervention at 12:08 p.m. and 8:29 p.m. and/or patient refusal of pain level assessments/reassessments.

On 2/21/25 at 5:06 a.m., 1:57 p.m. and 8:54 p.m., Ibuprofen 200 milligrams 4 tablets by mouth. The medical record lacked documentation of a pain level assessment prior to pain intervention, a reassessment 60 minutes after a pain intervention at 6:06 p.m., 2:57 p.m. and 9:54 p.m. and/or patient refusal of pain level assessments/reassessments.

On 3/1/25 at 5:20 a.m., 1:24 p.m. and 8:43 p.m., Ibuprofen 200 milligrams 4 tablets by mouth. The medical record lacked documentation of a pain level assessment prior to pain intervention, a reassessment 60 minutes after a pain intervention at 6:20 p.m., 2:24 p.m. and 9:43 p.m. and/or patient refusal of pain level assessments/reassessments.

3. During an interview with A2 (Assistant Director Quality & Compliance) on 4/10/25 at approximately 4:00 p.m., A2 verified the medical record information for patient #1.