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A. Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #1) clinical records reviewed for nursing assessments, the Hospital failed to conduct a pain reassessment, to ensure that the nursing care for each patient was evaluated.

Findings include:

1. On 10/12/2022, the clinical record for Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital on 6/6/2022 for acute inpatient rehabilitation. On 6/6/2022 at 6:26 PM, E #2 (RN/registered nurse) assessed Pt. #1's lower back pain as continuous, aching and throbbing. Pt. #1's pain score was 6 (moderate intensity). E #2 utilized relaxation technique for Pt. #1's pain. There was no pain reassessment after E #2's intervention. At 10:24 PM (approximately four hours after Pt. #1 complained of pain), Pt. #1's pain was scored as 7 (severe pain).

2. On 10/12/2022, the Hospital's policy titled, "The Hospital's policy titled, "Nursing Documentation (Charting) Guidelines - Assessment and Reassessment" included, " ... F. Documentation of Patient Assessments ... 1 ... iii. Pain reassessment - document pain assessment when a patient has pain and reassessment post administration of pain medication or other pain intervention within an hour ..."

3. On 10/12/2022 at approximately 11:30 AM, findings were discussed with E #7 (Nurse Manager, Stroke Unit). E #7 stated that a pain reassessment should have been conducted an hour after each pain intervention.

B. Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #1) clinical records reviewed for skin/wound care, the Hospital failed to supervise the care for each patient by ensuring that the physician's wound care order was followed.

Findings include:

1. On 10/12/2022, the clinical record for Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital on 6/6/2022 for acute inpatient rehabilitation. On 6/19/202, the clinical record included a physician's order for wound care to apply Betadine (antiseptic solution) to (left) lower back incision (and) cover it, and the (right) lower back incision (cover with) Mepilex 4 x 4 (type of dressing). Change dressings daily. The clinical record did not indicate that wound care dressing order was followed on 6/19/2022, 6/20/2022 and 6/21/2022.

2. On 10/12/2022, the Hospital's job description for registered nurses (dated 5/2021) was reviewed and included, "The Staff Nurse... complies with all relevant policies, procedures... Scope: Responsible for the... implementation... of patient care from a patient's admission through discharge..."

3. On 10/13/2022 at approximately 10:30 AM, findings were discussed with E #7 (Nurse Manager, Stroke Unit). E #7 stated that the physician's order for wound care should have been followed. E #7 could not provide documentation that the physician's order was followed.