HospitalInspections.org

Based on record review, interview, policy review, and document reviews, the hospital failed to ensure nursing staff reassessed eight of 24 patients (Patient (P)10, P11, P13, P14, P15, P17, P18 and P23) sampled for a reassessment after administering narcotic medications. The failure to reassess has the potential to place all patients in the facility receiving pain medication at risk for undetected adverse reactions or uncontrolled pain.

Findings Include:

A review of the facility policy titled, "Provision of Care Evidence Based Clinical Documentation," dated October 2020, showed, "d) Pain Assessment, i) Comfort levels are assessed using appropriate pain scale for developmental age. ii) Pain is assessed with all assessments, reassessments, and vital signs. iii) Pain is assessed before, during, and after procedures/treatments."

Review of a document titled, "PAIN Policy Updates- Oct 5th, 2020" showed, " ...Reassessment should occur 15-30 minutes following administration of IV pain medication and 60 minutes following administration of P.O. [by mouth] or I.M. [intramuscular] pain medication" ...

Patient 10

Review of P10's electronic record showed P10 was given oxycodone hydrochloride (HCL) 10 milligrams (mg) by mouth (PO) for pain on 03/12/21 at 1:49 PM. Review of the "Medication Discharge Summary" showed there was no reassessment documented following the administration of the pain medication.

Patient 11

Review of P11's electronic record showed P11 was given hydrocodone 5 mg with acetaminophen 325 mg (hydrocodone/APAP 5/325) mg PO for pain on 03/25/21 at 2:56 PM. Review of the "Medication Discharge Summary" showed there was no reassessment documented following the administration of the pain medication.

Patient 13

Review of P13's electronic record showed P13 was given oxycodone HCL 10 mg PO for pain on 03/08/21 at 1:20 PM. Review of the "Medication Discharge Summary" showed there was no reassessment documented following the administration of the pain medication.

Patient 14

Review of P14's electronic record showed P14 was given hydrocodone/APAP 5/325 mg PO for pain on 03/29/21 at 3:54 PM. Review of the "Medication Discharge Summary" showed there was no reassessment documented following the administration of the pain medication.

Patient 15

Review of P15's electronic record showed P15 was given hydrocodone/APAP 5/325 mg PO for pain on 03/18/21 at 8:22 AM. Review of the "Medication Discharge Summary" showed there was no reassessment documented following the administration of the pain medication.

Patient 17

Review of P17's electronic record showed P17 was given oxycodone HCL 10 mg PO for pain on 03/14/21 at 2:34 PM. Review of the "Medication Discharge Summary" showed there was no reassessment documented following the administration of the pain medication.

Patient 18

Review of P18's electronic record showed P18 was given oxycodone HCL 10 mg PO for pain on 03/23/21 at 3:04 PM. Review of the "Medication Discharge Summary" showed there was no reassessment documented following the administration of the pain medication.

Patient 23

Review of P23's electronic record showed P23 was given fentanyl 25 micrograms (mcg) intravenously (IV) for pain on 03/01/21 at 11:35 AM. Review of the "Medication Discharge Summary" showed there was no reassessment documented following the administration of the pain medication.

During an interview on 11/23/21 at 3:11 PM, the Director of Acute Care stated, "We are required to reassess patients in 30 minutes after giving intravenous (IV) pain medication and 1 hour after giving oral pain medication." The Director of Acute Care confirmed that the nursing staff did not meet this requirement in eight of 24 records reviewed.