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Based on a review of a medical record and facility policy, it was determined that the facility failed to ensure that the delivery of nursing services and assessment was performed when one (P#1) of six (P#1, P#2, P#3, P#4, P#5 and P#6) patients reviewed was given pain medication, upon rating a pain level of six out of 10, on 11/19/23 at 5:03 p.m. with no reassessment of the pain level through disposition.

Findings included:

Continued review of the medical record revealed that on 11/19/23 at 5:03 p.m. RN AA administered oxycodone 10 mg (pain medication) to P#1 with a pain assessment of six. No pain reassessment was performed.

A review of the facility's policy titled, "Nursing Patient Assessment/Reassessment Policy", policy #12930386, last revised 1/16/23, revealed that the purpose of the policy was to establish guidance for assessing and reassessing patients. It is the policy of the facility to ensure that all patients receive the appropriate assessment provided by qualified individuals within the facility, that the assessment process is multi-disciplinary, interdisciplinary, and that assessing patients is a continuous, collaborative effort with all departments functioning as a team. The patient, family/significant other, are considered an integral part of the process.
Continued review revealed that the nurse will review assessment data collected each shift to determine the patient's progress toward discharge and to identify if additional problems are present which require new or modified interventions.

A review of the facility's policy titled, "Rights and Responsibilities of Patients", policy #13089726, last revised 2/6/23, revealed that the purpose of the policy was to acknowledge patient's rights and responsibilities and the facility's responsibility to respond to each patient with personal dignity and respect.

Continued review revealed that all patients have the right to access to treatment within the capacity and scope of the facility to respect and support the patient's right to impartial access to treatment and services that are consistent with relevant laws and regulations and medically indicated, regardless of races, creed, sex, sexual orientation, gender identity or expression, national origin, religion, age, disability, diagnosis, or sources of payment for care.