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Based on interview and record review, the hospital failed to ensure the registered nurse evaluated the nursing care for four of 30 sampled patients when pain assessment and/or reassessment was not done for Patients 6, 20, 30, and 22. This failure had the potential for patients to have continued pain.

1. Patient 6 was admitted to the hospital on 10/29/24 for Hypoxic Respiratory Failure (a condition where not enough oxygen in the body).

During a concurrent interview and record review, on 1/14/25 at 9:28 a.m., with Nursing Quality Management Coordinator A (NQMC A) , Patient 6's pain was assessed on 11/26/24 at 4:00 a.m., 11/28/24 at 7:49 p.m., and 12/3/24 at 5:08 p.m. prior to administration of Oxycodone (a narcotic used to treat moderate to severe pain). NQMC A confirmed that there was no pain reassessment done within 1 hour after administration of pain medication.

Patient 6's pain was not assessed prior to administration of Oxycodone on 11/28/24 at 2:02 a.m., and no pain reassessment conducted within one hour after administration of pain medication. NQMC A confirmed there was no pain assessment and reassessment done.

Patient 20 was admitted to the hospital on 11/14/24 for infection (a disease caused by microorganisms that invade tissue).

During a concurrent interview and record review, on 1/15/25 at 10:42 a.m., with NQMC B, Patient 20's pain was assessed on 11/30/24 at 5:44 a.m., with pain level of 6 of 10, and Oxycodone was administered. NQMC B confirmed there was no pain reassessment done within one hour after administration of pain medication.

Patient 30 was admitted to the hospital on 11/25/24 for sepsis (the body's response to an infection).

During a concurrent interview and record review, on 1/15/25 at 1:54 p.m., with NQMC B, Oxycodone was administered to Patient 30 on 1/14/25 at 7:35 p.m. without pain assessment. NQMC B confirmed there was no pain assessment prior to administration of pain medication.




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2. Patient 22 was admitted to the hospital on 1/11/25.

During a concurrent interview and record review, on 1/15/25 at 2:12 p.m., with NQMC B, Tylenol 650 mg was administered orally to Patient 22 on 1/11/25 at 5:55 p.m. NQMC B confirmed there was no pain reassessment done within one hour after administration of pain medication.

During a review of the hospital's policy and procedure (P&P), titled "Standards of Practice for Acute and Critical Care Nursing", last approval date 11/24, indicated "Pain assessment (reassess within 1 hour of intervention)."

During a review of the hospital's P&P, titled "Pain Management', last approval date 12/21, indicated "(II)(C) Guiding principles for assessment and treatment of pain ...(4) Patients should be assessed for adequacy of pain control ...(IV)(B)(2)(a) pain is assessed upon admission/arrival to the patient care area ...and includes assessment ...interventions ..."