HospitalInspections.org

Based on clinical record review, policy review and interview, it was determined the Facility failed to ensure follow up pain assessments were completed after PRN (as needed) pain medications were administered to five (#1, #2, #4, #7 and #9) of seven (#1, #2, #4, #5 and #7-#9) patients. The failed practice did not ensure the effectiveness of the pain medication and created the potential for the patient to remain in pain; and could affect any patient admitted to the Facility. Findings follow.

A. Review of policy titled "Pain Management" stated, "All oral pain medications will be assessed within forty five minutes to one hour after administration. IV/IM (intravenous/intramuscular) pain medications will be reassessed within thirty minutes of administration."

B. Review of clinical records revealed the following:
1) Patient #1 - no follow up assessment for 4 of 11 PRN pain medications given.
2) Patient #2 - no follow up assessment for 3 of 11 PRN pain medications given.
3) Patient #4 - no follow up assessment for two of two PRN pain medications given.
4) Patient #7 - no follow up assessment for one of one PRN pain medications given.
5) Patient #9 - no follow up assessment for two of six PRN pain medications given.

C. During clinical record review on 11/26/14 from 0830 to 1025, the Chief Nursing Officer confirmed the follow up assessments for PRN medications were not done.