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Based on medical record review, policy review and staff interview, the Critical Access Hospital (CAH) staff failed to provide evidence of assessment and/or re-assessment of the patient's pain or response to interventions for pain for three of the 11 sampled patients (Patient 12, Patient 18 and Patient 19).

Findings Include:

A review of Patient 12's electronic medical record "Physician Orders" tab showed, while being treated in the Emergency Department (ED) for abdominal pain, the patient received Morphine Sulfate (MS) two (2) milligrams (mg) Intravenous (IV) for pain at 9:30 PM. Patient 12 was admitted to the observation unit at 11:36 PM. The "admission nursing assessment" showed at that time that the patient's pain level was a "4". There was no documentation to indicate that the patient's level of pain was tolerable, or if the patient required further interventions for comfort.

A review of Patient 18's Electronic medical record "Physician Orders" tab showed the patient was admitted to the acute care unit on 01/20/19 at 9:10 PM for pneumonia and pancreatitis. The part of the "nursing assessment" that addresses pain was marked "Yes." However, there was no further documentation to determine the parent's location, level, quality or intensity of pain or if the patient required intervention for comfort.

A review of Patient 19's electronic medical record "Physician Orders" tab showed the patient was admitted to the Emergency Department (ED) on 01/27/19 at 10:47 AM for abdominal pain, nausea and vomiting. The patient reported a pain level of "9" for which Tylenol was given for pain. The patient was discharged on 01/27/19 at 1:30 PM and there was no further documentation to indicate that the patient's pain was re-assessed to determine if the Tylenol was effective or if the patient required further interventions to control the pain.

After a review of the facility's CAH's policies, it was determined there were no policies in place to address re-assessment of pain interventions or the documentation required to support a pain assessment.

In an interview during record review on 02/05/19 at 10:00 AM, Staff J, Director of Nursing (DON) confirmed the above findings and stated, "We have been discouraged from writing notes in Cerner and encouraged to use the templates to capture the needed documentation. I feel like we are spending more time clicking the blocks, which are often redundant, instead of capturing the appropriate information. Sometimes I think the nurses mark certain blocks unintentionally in error."

Based on interview, record review, and policy review, the Critical Access Hospital (CAH) failed to ensure that one of five sampled patients (Patient 6) received a dietary assessment after being admitted to the hospital as a swing bed patient. This deficient practice had the potential for the patient to be given a diet that was not appropriate.

Findings Include:

Review of Patient 6's undated, "Patient Information" sheet revealed an admission date of 01/30/19 with the following diagnoses of sepsis (a life-threatening complication of an infection), influenza A, chronic obstructive pulmonary disease, chronic heart failure and chronic renal failure. The "Physician orders" dated 01/30/19 showed an order for a nutritional assessment. Patient 6 was discharged home on 02/04/19. Further medical record review revealed an Adult Initial Assessment/ Plan entered on 02/05/19 (one day after the patient discharged) completed by the Registered Dietician (RD).

During an interview on 02/05/19 at 12:39 PM, Staff G, RD who oversees food services, stated that she has been distracted with other duties. Staff G was asked how the orders are received by the dietary staff. Staff G stated the orders prints out in the kitchen. Staff G stated, "Nursing staff at one point, used to alert the dietician but that was not the case anymore." Staff G stated that she was, "not aware of the policy stipulating a specific time frame but she tries to see the patients within 48 hours." Staff G was asked why the assessment was completed after Patient 6 was discharged from the hospital. Staff G stated, "I was trying to catch up even though the patient was no longer in the hospital. We dropped the ball."

During an interview on 02/06/19 at 9:19 AM, Staff N, food service manager, stated that the orders come through on the printer and if they are for the dietician than they are placed in the bin. Staff N stated that she reviews the orders and that one got away from them.

Review of the CAH's policy titled, "Inpatient Medical Nutritional Therapy," revised 10/2017 indicated, Provide nutritional screening of all inpatients to determine level of care required to establish patient needs, to be completed no greater than 72 hours following admission.