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Based on observation, interview and record review the facility failed to implement an individualized patient plan of care for 1 of 13 sampled patients (Patient 4) when no pain management plan was initiated.

This failure prevented the staff from assessing and communicating an effective and consistent pain management program to alleviate Patient 4's pain.

Findings:

A review of the electronic medical record (eMR) for Patient 4 indicated she was admitted to the hospital on 2/11/19 for a lung tumor and subsequent surgery.

During a tour of the facility on 2/14/19 at 9:40 a.m., Patient 4 stated, "They [the nurses] usually don't usually ask me about pain... I ask for pain meds [medications]. They give me medication, but doesn't work well." Patient 4 additionally stated the nurses had been notified of the inadequate pain control.

During an interview on 2/14/19 at 9:45 a.m., Registered Nurse (RN) 1 stated she had done additional comfort measures for Patient 4, including repositioning and encouraging the patient to deep breathe. RN 1 additionally stated these measures would be found in the care plan.

A concurrent interview and eMR review of Patient 4, with the Clinical Educator (CE), was done on 2/14/19 at 11:30 a.m. which revealed Patient 4 did not have a pain management plan of care. The CE concurred there was not patient plan for pain in the eMR.

During an interview with the Director of Intensive Care Unit (DICU) on 2/14/19 at 1:30 p.m., the DICU stated there was no pain plan of care for Patient 4.

A review of the facility policy titled Pain Assessment and Management, dated 3/7/17, stipulated "Purpose: To provide clinical practice expectations and guidance to facilitate individualized, effective pain management designed to enhance patient comfort and function, promote optimal outcomes, and facilitate patient/family satisfaction....Develop an individualized pain management plan in collaboration with the patient/family and members of the interdisciplinary team and document in the Plan of Care."