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Based on record review and interview, for one of one sampled patient (Patient), the Hospital failed to ensure that the staff followed the Assessment and Management of Pain Policy and the Patients Receiving Medication via Epidural Catheters, Guideline for Management Policy.

Findings included:

1. The Assessment and Management of Pain Policy indicated that reassessment of pain after pain intervention must be made to evaluate the effectiveness of the intervention. The Policy indicated that reassessment was to be done within an appropriate timeframe based on the intervention.

The Pain Assessment and Intervention Flow sheet, dated 1/30/10, at 4:00 P.M., indicated that the Patient had a pain rating of 6 out of a pain scale of 0 to 10, 0 being no pain and 10 being the worst possible pain and the Patient was started on a patient controlled analgesic (PCA) morphine pump at a maximum dose of 10 milligrams (mg) every 4 hours.

The plan of care indicated that the Patient's acceptable level of pain was less than 4.

The Assistant Nurse Manager was interviewed on 2/11/10, at 11:20 A.M. The Assistant Nurse Manager said the Hospital's Policy included assessing a patient's pain every 4 hours and assessing a patient's pain within 15 to 30 minutes after the administration of pain medication. The Assistant Nurse Manager said if the Patient's pain rating was greater than 3, interventions were to be initiated with a follow-up pain assessment.

The Pain Assessment and Intervention Flow sheet, dated 1/30/10, at 8:00 P.M., indicated that the Patient had a pain rating of 6; the Patient received 4 mg of morphine during the past 4 hours, and there was no post pain assessment rating.

The Pain Assessment and Intervention Flow sheet, dated 1/31/10, at 4:00 P.M., indicated that the Patient had a pain rating of 4; the Patient received morphine via the PCA pump and there was no post pain assessment rating.

The Pain Assessment and Intervention Flow sheet, dated 1/31/10, at 8:00 P.M., indicated that the Patient had a pain rating of 5; the Patient received 4 mg of morphine via the PCA pump since 4:00 P.M., and there was no post pain assessment rating.

The Pain Assessment and Intervention Flow sheet, dated 2/1/10, at 8:00 A.M., indicated that the Patient had abdominal pain that was not rated; the Patient receive morphine via the PCA pump, and there was no post pain assessment rating.

The physician order sheet, dated 2/1/10, included the narcotic pain medication, Percocet 2 tablets every 4 hours as needed (prn) for severe pain.

The Pain Assessment and Intervention Flow sheet, dated 2/1/10, at 3:00 P.M., indicated that the Patient had abdominal pain that was not rated and the Patient received 2 tablets of Percocet.

The Pain Assessment and Intervention Flow sheet, dated 2/1/10, at 8:30 P.M., indicated that the Patient had a pain rating of 4; the Patient received 2 tablets of Percocet and there was no post pain assessment rating.

The Pain Assessment and Intervention Flow sheet, dated 2/3/10, at 5:30 A.M., indicated that the Patient had a pain rating of 6; the Patient received 2 tablets of Percocet, and there was no post pain assessment rating.

The Pain Assessment and Intervention Flow sheet, dated 2/3/10, at 11:45 A.M., indicated that the Patient had a pain rating of 6; the Patient received 2 tablets of Percocet, and there was no post pain assessment rating.

The Pain Assessment and Intervention Flow sheet, dated 2/3/10, at 9:30 P.M., indicated that the Patient had a pain rating of 5; the Patient received 2 tablets of Percocet, and there was no post pain assessment rating.

The Assistant Nurse Manager said the staff did not consistently reassess the Patient's pain after the administration of pain medication per the Hospital Policy

Although the PRN Medication Administration Record indicated that the Patient received 2 tablets of Percocet on 2/4/10, at 7:00 P.M., the Pain Assessment and Intervention Flow sheet, dated 2/4/10, at 7:00 P.M., did not indicate that the Patient received any pain medication and the Patient had no pain assessment rating,

Although the PRN Medication Administration Record indicated that the Patient received 2 tablets of Percocet on 2/5/10, at 12:10 A.M., the Pain Assessment and Intervention Flow sheet, dated 2/5/10, at 12:10 A.M., did not indicate that the Patient received any pain medication and the Patient had no pain assessment rating,

The Assistant Nurse Manager said any time a prn pain medication was administered to a patient, the Pain Assessment and Intervention Flow sheet was to be completed. The Assistant Nurse Manager said on 2/4/10, at 7:00 P.M., and on 2/5/10, at 12:10 A.M., the nurses did not assess the Patient's pain and document their findings on the Pain Assessment and Intervention Flow sheet per the Hospital Policy.

2. The Patients Receiving Medication via Epidural Catheters, Guidelines for Management Policy indicated that the patient's blood pressure, pulse, and oxygen saturation level were to be checked every 5 minutes for 4 times whenever there was an increase in the rate of pain medication via an epidural.

The Pain Assessment and Intervention Flow sheet, dated 1/28/10, indicated that at 7:00 P.M., the Patient's epidural was increased to 11 cubic centimeters (cc).

There was no evidence on 1/28/10, between 7:00 P.M. and 7:20 P.M. that the Patient's blood pressure, heart rate, and oxygen saturation level were obtained per the Patients Receiving Medication via Epidural Catheters, Guidelines for Management Policy.

The Medical/Surgical flow sheet, dated 1/28/10, indicated that the Patient's blood pressure, heart rate, and oxygen saturation level were not obtained until 7:59 P.M.

The Pain Assessment and Intervention Flow sheet, dated 1/29/10, indicated that at 12:01 A.M., the Patient's epidural was increased to 12 cc.

There was no evidence on 1/29/10, between 12:01 A.M. and 12:21 A.M. that the Patient's blood pressure, heart rate, and oxygen saturation level were obtained per the Patients Receiving Medication via Epidural Catheters, Guidelines for Management Policy.

The Medical/Surgical flow sheet, dated 1/29/10, indicated that the Patient's blood pressure, heart rate, and oxygen saturation level were not obtained until 3:59 A.M.