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Based on interview and record review, the hospital failed to ensure the pain reassessment and management for one of nine sampled patients (Patient 5) was conducted as per the hospital's P&P. This failure had the potential for unsafe care to the patient.

Findings:

Review of the hospital's P&P titled Pain Management dated 10/21/24, showed the following:

* Interventions for Pain Relief:

- Non-pharmacological interventions include but are not limited to the following examples:

1. Turning or repositioning

2. Cold or heat application which is hospital approved

- Pharmacological interventions

* Documentation:

- Documentation of pre and post medication administration is done on the Pain/Comfort/Sleep portion of the Flowsheet in the EHR. A number value of 0-10 based on the patient's self-evaluation and/or the RN's evaluation of all variables is used.

- Document pain level (if self-report) or APP (if unable to self-report) prior to administration of analgesic. Document re-assessment or self-report pain level after designated timeframe.

On 2/6/25 at 0907 hours, Patient 5's closed medical record was reviewed with Nursing Director 1 in the presence of the Accreditation and Regulatory Compliance Supervisor.

Patient 5's closed medical record showed Patient 5 was admitted to the hospital on 12/3/24 and discharged on 12/5/24.

Review of the flowsheets for the pain and medication administration records showed the following:

* On 12/4/24 at 0802 hours, Patient 5 complained of pain eight out of 10 (on a 0 to 10 pain scale, 0 being no pain and 10 being the worst pain). Patient 5 received Dilaudid (a pain medication) 0.4 mg IVP at 0802 hours. Further review of Patient 5's the medical record showed on 12/4/24 at 0832 hours, "pain reduced." However, there was no documented evidence showing the patient's pain level as per the hospital's P&P.

* On 12/4/24 at 1139 hours, Patient 5 complained of pain five out of 10. Patient 5 received tramadol (a pain medication) 50 mg by mouth at 1139 hours. At 1239 hours, Patient 5 reported the pain intervention was not effective.

* On 12/4/24 at 1348 hours, Patient 5 complained of pain eight out of 10. Patient 5 received Dilaudid 0.4 mg IVP at 1348 hours. Further review of Patient 5's medical record showed on 12/4/24 at 1418 hours, "pain reduced interventions effective." However, there was no documented evidence showing the patient's pain level as per the hospital's P&P.

When asked, Nursing Director 1 stated Dilaudid 0.4 mg was ordered to administer to the patient every two hours as needed. Patient 5 received Dilaudid 0.4 mg on 12/4/24 at 0802 and 1348 hours. Further review of Patient 5's medical record failed to show any pain intervention provided to the patient when Patient 5 reported the pain intervention was not effective for one hour nine minutes.

The Accreditation and Regulatory Compliance Supervisor and Nursing Director 1 verified the above findings.

Based on interview and record review, the hospital failed to ensure the ED nursing staff provided the pain medication to one of nine sampled patients (Patient 1) as ordered by the physician, creating the risk of unrelieved pain for the patient and substandard outcomes.

Findings:

Review of the hospital's P&P titled Emergency Department: Patient Assessment, and Reassessment dated 9/17/24, showed the purpose of the P&P is to guide the RN with assessing and documenting the primary assessment, secondary assessment, and reassessments of ED patients. It serves to provide a patient data base for the identification of patient chief complaints, plan of care, documentation of nursing interventions, and evaluation of the care given. The primary RN who assumes care will perform complaint-based assessments and reassessments throughout the patient stay.

On 2/5/25 at 1021 hours, Patient 1's closed medical record was initiated with the Sr. Principle Regulatory Compliance and Corporate Facilities.

Patient 1's closed medical record showed Patient 1 visited the ED on 1/4/25, was admitted to the hospital and discharged on 1/5/25.

Review of the Patient Care Timeline showed Patient 1 arrived to the ED on 1/4/25 at 1217 hours. At 1241 hours, the patient reported increased flank pain and fever. By 1243 hours, a pain assessment recorded a numeric pain score of 10 out of 10 with the patient describing constant, sharp pain in the bilateral back.

Review of the physician's order dated 1/4/25 at 1600 hours, showed to administer morphine (a pain medication) 4 mg/ ml IV every 20 minutes for severe pain (7-10) and to discontinue at 1949 hours after two doses.

Review of the Pain Monitoring assessments and the MAR showed Patient 1 reported severe pain; however, the morphine was not administered to the patient as ordered. For example:

- On 2/4/25 at 1700 hours, Patient 1 stated a pain level of seven out of 10 (or severe pain). Morphine was not administered, and no additional interventions to address the pain was documented.

- At 1816 hours, Patient 1 stated a pain level of 10 out of 10 (or severe pain) and was administered 4 mg morphine IV.

- At 1854 hours, Patient 1 stated a pain level of 8 out of 10 (or severe pain). However, morphine was not administered and no additional interventions to address the pain was documented.

- At 1949 hours, Patient 1 stated a pain level of eight out of 10 (or severe pain). Morphine 4 mg IV was administered to the patient.

On 2/6/25 at 1004 hours, the above findings were shared with the Sr. Principle Regulatory Compliance and Corporate Facilities.