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Based on hospital protocol, interview and medical record review, the facility did not assure that Patient #1's pain was assessed prior to or post medication administration per hospital protocol.

Findings include:

Review of the hospital's Nursing Practice Standard protocol " Patients Experiencing Pain " (issued 4/2008) revealed, under Assessment, that the intensity of a patient's pain is reported on a scale of 0 - 10 (0 = no pain, 10 = most pain ever experienced). Under Pain Management Intervention, that the effectiveness of the administration of intravenous (IV) narcotics should be assessed 15 minutes following administration and the effectiveness of the administration of oral analgesics should be assessed 60 minutes following administration. This was verified on February 22, 2010 with Staff #1.

Review of the Emergency Department (ED) Documentation Tool, dated November 25, 2009 revealed the following:

-Morphine 2 mg IV was administered at 8:05 PM and 9:20 PM for 10/10 pain. An assessment of the effectiveness of these medications was done 70 minutes after administration.

-Morphine 4 mg IV was administered at 10:55 PM for 10/10 pain. An assessment of the effectiveness of this medication was done 55 minutes after administration.


Review of the W4 Patient Medication Records and Pain Assessment Flowsheets, dated November 26, 2009 revealed the following:

-Morphine 4 mg IV was administered at 5:15 AM for " hurts a lot " . An assessment of the effectiveness of this medication was done 35 minutes after administration.

-Roxicodone IR 5 mg orally was administered at 10:30 AM for " hurts a lot " . An assessment of the effectiveness of this medication was not done.

-Morphine 2 mg IV was administered at 12:50 PM and Morphine 4 mg IV was administered at 1:45 PM. The patient's pain level and an assessment of the effectiveness of these medications were not done.

-Morphine 2 mg IV was administered at 6:45 PM. The patient's pain level was not documented and an assessment of the effectiveness of this medication was done 30 minutes after administration.


Review of the W4 Patient Medication Records and Pain Assessment Flowsheets, dated November 27, 2009 revealed the following:

-Morphine 2 mg IV was administered at 10:40 AM and 1:50 PM and Morphine 4 mg IV
was administered at 5:50 PM and 7:10 PM. The patient's pain level and an assessment of the effectiveness of these medications was not done.

-Oxycodone IR 5 mg orally was administered at 4:10 PM for 10/10 pain. An assessment of the effectiveness of this medication was not done.

-Oxycodone 5 mg orally was administered at 10:45 PM. The patient's pain level was not documented and an assessment of the effectiveness of this medication was not done.


Review of the W4 Patient Medication Records and Pain Assessment Flowsheets, dated November 28, 2009 revealed the following:

-Morphine 2 mg IV was administered at 9:30 AM for 5/10 pain. An assessment of the effectiveness of this medication was done 30 minutes after administration.

-Morphine solution 2 mg orally was administered at 1:50 PM. The patient's pain level and an assessment of the effectiveness of this medication were not done.