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Based on interview and record review the hospital failed to follow their Policy and Procedures (P&P) to complete a care plan for one of 30 sampled patients (Patient 21) when Patient 21 did not have a care plan for pain management.

Findings:

During a concurrent interview and record review on 9/24/24 at 3:18 p.m. with Health Information Manager (HIM), Patient 21's "Pain Assessment (PA) and Medication Administration Record (MAR)," dated 9/23/24, the PA indicated, Patient 21 had lower abdominal pain. The MAR indicated Patient 21 was given pain medication at 11:24 a.m.

During a concurrent interview and record review on 9/24/24 at 3:18 p.m. with HIM, Patient 21's "Medical Records (MR)," undated, the MR indicated Patient 21 did not have a care plan for pain management.

During an interview on 9/25/24 at 12:53 p.m. with Registered Nurse (RN), RN stated for a patient who complains of pain, she would assess the pain score and check if the was an order for pain medication. RN stated she would start the pain care plan right away when a patient complains of pain.

During a review of the hospital's policy and procedure (P&P) titled, "Pain Assessment and Management Standards," dated 10/27/22, the P&P indicated, "Educate patient and family on discharge plans related to pain management including: plan of care, side effect of pain management treatment."

During a review of the hospital's P&P titled, "Nursing Diagnosis/Patient Problems/Care Plan," dated 4/27/23, the P&P indicated, "c. A written patient care plan is developed for each hospitalized patient by use of the nursing process: a problem-solving method consisting of assessment, planning, intervention, and evaluation. The care plan includes physiological, psychological, and environmental factors."