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Based on record review and interview the facility staff failed to reassess pain levels following interventions per facility policy for 3 of 6 Patients (Patient #5, 6 and 10) in a total universe of 10.

Findings include:

Review of facility policy titled, "Pain Management Resource" #8069523 dated 05/15/2023 revealed, "II. Reassessment a. Reassessment includes pain intensity/score, adverse effects, and sedation (for patients receiving opioid analgesics). b. Reassess once a sufficient time has elapsed for the treatment to be effective. For pharmacologic interventions, timing of reassessments should consider drug, dose, and route. i. Suggested reassessment is 15-30 minutes after IV administration and 60-120 minutes after oral administration."

Review of Patient #5's medical record revealed a hospital admission date of 07/03/2021 through 07/30/2021 related to a fall. Patient #5 received hydrocodone (pain medication) 5 mg orally on 07/14/2021 at 8:50 PM for severe pain. There was no documented reassessment of pain completed. Patient #5 received hydrocodone 5 mg orally due to severe pain on 07/19/2021 at 12:16 PM, there was no documented reassessment of pain completed. On 07/25/2021 at 6:45 PM Patient #5 received hydrocodone 5 mg orally for complaint of severe pain. There was no documented reassessment of pain completed. On 07/26/2021 at 1:56 PM, hydrocodone 5 mg was given orally for complaint of severe pain, There was no documented reassessment of pain completed.

Review of Patient #6's medical record revealed a hospital admission date of 08/21/2021 and remains a current patient due to fall resulting in a fracture. Patient #6 received acetaminophen 650 mg orally on 08/21/2021 at 1:38 AM, 5:51 AM, 10:22 AM, 2:43 PM and 11:36 PM, for complaints of mild pain. There was no documented reassessments of pain completed. Received tramadol 50 mg orally for complaint of moderate pain on 08/25/2021 at 5:21 AM. There was no documented reassessment of pain completed. Patient #6 received acetaminophen 650 mg orally on 08/27/2021 at 6:42 PM for complaint of mild pain. No reassessment was documented. Patient #6 received acetaminophen 650 mg orally on 08/28/2021 at 1:20 AM for complaint of mild pain. There was no documented reassessment of pain. Received Tramadol 50 mg on 08/29/2021 at 11:28 PM for complaint of severe pain and acetaminophen 325 mg at 3:37 AM for complaint of mild pain. There was no documented reassessments of pain. Patient #6 received ibuprofen 800 mg orally on 08/30/2021 at 9:30 PM for complaint of moderate pain. No reassessment was documented.

Review of Patient #10's medical record revealed a hospital admission date of 06/04/2021 through 06/05/2021 due to loss of consciousness. On 06/04/2021 at 8:30 AM Patient #10 received acetaminophen 650 mg orally due to mild pain, there was no documented reassessment.

During an interview on 09/02/2021 at 1:09 PM, Manager of 3 North Medical Unit confirmed the findings and stated, the nurses should be completing a pain reassessment within 120 minutes of medications being given.