HospitalInspections.org

Based on staff interview, review of two (2) of three (3) medical records, and review of facility policy and procedure, it was determined the facility failed to ensure that pain is reassessed timely, after pain interventions, in accordance with facility policy.

Findings include:

Reference: Facility policy titled, "Vital Signs (Inclusive of Pulse Oximetry, Pain Scale) & Height and Weight Measurements for Adult Patients" states, "... Pain assessment is documented... within one hour of an oral pain intervention and 15 minutes after IV (intravenous) analgesic, on all patient areas."

1. Upon review of Medical Record #1, the following was noted:

a. On 11/16/20 at 21:49, the patient had a pain rating of seven (7) out of ten (10). Toradol 15 mg (milligrams) IV push was administered.

i. A pain assessment was documented at 23:08, with the patient receiving a pain rating of seven (7).

ii. The assessment was performed one (1) hour and nineteen (19) minutes after the intravenous analgesic was administered.

b. On 11/16/20 at 23:08 the patient had a pain rating of seven (7) out of ten (10). Morphine 4 mg IV push was administered.

i. A pain assessment was documented on 11/17/20 at 02:33, with the patient receiving a pain rating of four (4).

ii. The assessment was performed three (3) hours and forty-one (41) minutes after the intravenous analgesic was administered.

2. Upon review of Medical Record #2, the following was noted:

a. On 11/16/20 at 21:59, the patient had a pain rating of eight (8) out of ten (10). Acetaminophen Injection 1000 mg at 400 ml (milliliters) / hr (hour) was administered.

i. A pain assessment was documented on 11/17/20 at 01:20, with the patient receiving a pain rating of zero (0).

ii. The assessment was performed two (2) hours and twenty-one (21) minutes after the intravenous analgesic was infused.

3. The above findings were confirmed with Staff #10.