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Based on staff interview and record review, the hospital failed to assure that nursing staff provided care to all inpatients based upon their current needs for 1 of 7 applicable patients in the total sample. (Patient #1). Findings include:

Patient #1, who had a diagnosis of chronic pain, was admitted to the hospital on March 16, 2016 with severe dehydration (hypernatremia) and mental status changes and nursing staff failed to adhere to the assessment guidelines calling for assessment of each patient for pain at least every 4 hours. On day 2 of the stay, the patient exhibited signs indicative of pain, per a family member in attendance. The nurse was informed that the patient had been on twice daily pain medication before admission to the hospital and that the patient appeared to be in pain. The nurse on duty at 2203 Hr. assessed the pain level to be 4 out of 10 and notified the provider. Oxycodone, 5 mg. PO twice daily was ordered and administered.. The nurse reassessed the patient's pain at 2232 as level 0. There was no documented RN pain assessment between 2232 on 8/17/16 and 0800 on 8/18/16. The pain assessment at 0800 on 3/18/16 stated pain was 0. At 0943 on 3/18/16, the RN (Registered Nurse) documented the patient's pain level as 5 of 10 and administered a dose of Oxycodone; at reassessment at 1013, the pain was rated as 3 of 10.

Per review of the hospital's Policy "Guidelines for Vital Signs/PCA Monitoring", rev. 7/20/16, at reference H., Vital signs include temperature, HR; BP; Resp., Room Air or oxygen amount and O2 SAT, and pain level. At reference C,. VS are to be done, "every 4 hours on the medical surgical unit". The hospital's policy "Patient Hourly Rounding" states that patients should be asked "How is your pain?" at hourly rounds. There was no evidence of discussion of possible pain documented under the electronic check indicating that the hourly rounding was completed for this patient..
During interview on the last day of survey, the RN Supervisor for the medical-surgical unit confirmed the lack of evidence of pain assessment for Patient #1 at least every 4 hours, per policy, as well as during the hourly patient rounds.

Based on staff interview and record review, nurses failed to develop a care plan to address each of the current needs for 1 of 7 patients in the total sample. (Patient #1). Findings include:

Per record review and confirmed by interviews with hospital staff, Patient #1 experienced pain during a 3 day hospitalization and received medication to treat the pain symptoms. The care plan developed for this patient did not address the needs related to pain management, including assessment and treatment of the pain. This care plan omission was confirmed with hospital Nursing and Quality Assurance staff.
Refer also to C-0294