HospitalInspections.org

Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure that pain reassessment is completed in accordance with the facility policy in one of 10 medical records reviewed (MR1).

Findings include:

Facility policy titled, "Adult/Pediatric Pain Management" reviewed September 2022, stated, " ... E. Pain will be reassessed: 1. Following the administration of pain medication to determine the amount of pain control or relief achieved in a time interval not to exceed 2 hours ..."

A review of Patient (P)1's medical record, revealed the following:

On 2/1/25 at 10:56 AM, Staff (S)15 (Registered Nurse) administered Morphine (narcotic pain medication) 2mg IV. Upon further review, the medical record lacked documentation of an initial pain assessment and a pain re-assessment within 2 hours of administration of the medication morphine.

On 2/5/25 at 3:15 AM, the Omnicell [medication storage] transaction record revealed that S14 withdrew Morphine 2mg [milligrams]/1ml [milliliters] 1ml injection for P1. On 2/5/25 at 3:16 AM, the "Pain Flowsheet" documentation by S14 indicated that Morphine 2mg IV was administered for "6/10 generalized pain [six out of 10 pain scale]." The medical record lacked evidence that a pain re-assessment was performed after the administration of pain medication per facility policy.

On 3/24/25 at 1:58 PM, S7 (Nurse manager of ICU/Telemetry), S5 (Clinical Nurse Leader of Critical Care), and S1(Director of Patient Safety and Guest Relations) confirmed the above findings.