HospitalInspections.org

Based on record review and interview, the facility failed to;
1. Ensure staff performed pain assessment for seven of 10 sampled patients (Patient 15, 16, 18, 20, 21, 22, and 23) every shift as per their pain management policy and procedure.
2. Ensure staff performed pain assessment for three of 16 sampled patients (Patients 2, 5, and 11).

These failures had the potential for patients experiencing pain without being addressed by staff.

Findings:

1. The facility policy and procedure titled "Pain Management", dated 3/23/17, in part, (4) (4.3) indicated "The patient's pain level will be monitored at regular intervals as dictated by a physician's order but no less than every 12 hours or once per shift."

During a review of the clinical record for patients' 15, 16, 18, 20, 21, 22, and 23 and concurrent interview with the nursing supervisor (NS) on 9/25/19 at 8:45 a.m., patient 15's daily flow sheet, dated 9/17/19 was noted without a pain assessment during the day and night shift. Patient 16's daily flow sheets, dated from 9/13/19 to 9/16/19 were noted with day shift pain assessments only. Patient 18's daily flow sheets, dated from 9/13/19 to 9/16/19 were noted with day shift pain assessments only. Patient 20's daily flow sheets, dated 9/14/19 and 9/15/19 were noted with day shift pain assessments only. Patient 21's daily flow sheets, dated 9/15/19 and 9/16/19 were noted with day shift pain assessments only. Patient 22's daily flow sheet, dated 9/16/19 was noted with day shift pain assessment only. Patient 23's daily flow sheets, dated 9/16/19, 9/17/19 and 9/19/19 were noted with day shift pain assessments only. The NS acknowledged and confirmed that the flow sheets did not indicate pain assessments were performed every (day & night) shift as per their policy and procedure.

2. . The facility policy and procedure titled "Pain Management", dated 3/23/17, in part, (4) (4.3) indicated "The patient's pain level will be monitored at regular intervals as dictated by a physician's order but no less than every 12 hours or once per shift."

During a review of the clinical record for patients' 2, 5, and 11, and concurrent interview with licensed nurse (LN 2) on 9/24/19, beginning at 9:30 a.m., patient 2's daily flow sheet, dated 9/22/19, did not have any pain assessments documented. Patient 5's daily flow sheets, dated 9/10/19 and 9/17/19, did not have any pain assessments documented. Patient 11's daily flow sheet, dated 9/22/19, did not have any pain assessments documented. LN 2 acknowledged and confirmed that the daily flow sheets did not indicate any pain assessments were performed per facility policy and procedure.