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Based on medical record review, policy review, and interview, the facility failed to ensure a registered nurse evaluated the nursing care for one of eight medical records reviewed for pain (Patient #1). The total sample was 10 records. The facility's census was 131.

Findings include:

Review of the policy titled, Pain Management, Adult, approved 09/2023, revealed patients are screened for the presence of pain upon inpatient admission, during an emergency department visit, and at a visit to an ambulatory clinic that conducts risk screens (see Adult Patient Risk Screening (Outpatient), CP-131). If pain is present, a pain assessment is completed. Use a pain assessment scale/tool that is appropriate for age, development, and cognitive ability of the patient. Includes current and prior pharmacological and non-pharmacological interventions, including opioid use, for pain management and its impact on current reported pain and treatment interventions. Pain assessment consists of pain: Location; Intensity; and Description (i.e. quality, associated symptoms, etc.).

Review of Patient #1's medical record revealed he was evaluated in the facility's emergency department on 10/18/23 for complaints of abdominal pain.

Patient #1's pain assessments were as follows:
Date Time Level Location
10/18/23 5:05 AM 10 -
10/18/23 10:55 AM 10 -
10/18/23 5:15 PM 0 -
10/18/23 11:34 PM 9 -
10/19/23 3:05 AM 9 -
10/19/23 1:09 PM 8 -
10/19/23 7:58 PM 7 -
10/20/23 12:07 AM 10 -
10/20/23 5:15 AM 10 -

The pain documentation did not include the location of Patient #1's pain.

On 12/13/23 at 7:41 AM, the findings were shared with Staff C in an interview and confirmed.

On 12/13/23 at 1:59 PM, the findings were shared with Staff A in an interview and confirmed.