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Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, "Pain Management (General Patient Care Policy)", for one of 30 sampled patients (Patient 14), when staff administered a PRN (as needed) pain medication without charting a pain assessment following the indication (valid reason for using a medication) for use according to pain medication order. This failure resulted in Patient 14 to receive an unnecessary medication.

Findings:

During a review of Patient 14's medical orders, dated 2/23/25, order indicated, "Oxycodone (Roxicodone) [controlled pain medication] immediate release tablet 5 mg Nasogastric [tube entering nose down the throat to the stomach-used for nutrition feeding and medications in sedated patients] Every 4 hours PRN, CPOT >2 [Critical Care Pain Observation Tool (CPOT) rates critically ill patients' pain based on clinical observation. The possible total score ranges from 0 (no pain) to 8 (maximum pain)]".

During a review of Patient 14's Medication Administration Record (MAR), dated 2/24/25, MAR indicated, at 1739 (5:23 pm) Patient 14 was administered "oxycodone (Roxicodone) immediate release tablet 5 mg [milligrams]".

During a concurrent interview and record review on 2/25/25, at 11:48 a.m., with Assistant Director of Float Pool (ADF), Patient 14's "Flowsheet" dated 2/25/25 was reviewed. Patient 14's Flowsheet indicated, a CPOT assessment was completed at 1600 (4P.M.) with a score of 0. Flowsheet indicated, no CPOT assessment was charted at time of pain medication administration (1739). Flowsheet indicated a CPOT assessment was charted at 1800 with a score of 0. ADF stated, there is no CPOT assessment at time of pain medication administration.

During an interview on 2/25/25, at 2:30 p.m., with Assistant Director of Intensive Care Unit (ADI), ADI stated, their policy is, before a nurse can give a PRN pain medication, they need to complete a pain assessment.

During a review of the facility P&P titled, "Pain Management (General Patient Care Policy)", dated 2025, the P&P indicated, "1. Pain is assessed using an approved tool (Appendix A) . . . 2. If the patient has pain, the assessment tool is completed in its entirety by an RN. . . Appendix A: Scale Critical Care Pain Observation Tool CPOT".