HospitalInspections.org

Based on document review and interview the nursing staff failed to ensure the patients' rights and pain management policies were implemented related to follow up assessments after pain medication administration for 1 of 2 closed inpatient medical records, Patient #5.

Findings Include:
1. Review of the policy Patients' Rights and Responsibilities, policy number 903820, last approved 8/2014, indicated in Attachment A in the "Rights" section that: "...7. Appropriate assessment and management of pain...".

2. Review of the policy Pain Management: Adult and Pediatric, policy number 428193, last approved 11/2013 indicated on page 2 under "I. Pain Assessment - 24 Hour Care Settings": "...Pain intensity, description, and pain relief as reported by the patient will be assessed, treated as appropriate and documented: After a known pain-producing event. After each pain management intervention, once a sufficient time period has elapsed for treatment to reach peak effect. IV (intravenous) medications must be reassessed within 60 minutes PO (oral) immediate-release medications must be reassessed within 90 minutes...".

3. Review of medical records indicated Patient #5 received pain medication as follows:
A. On 7/14/16 at 1850 hours the patient was given Norco 5/325 mg two tablets with no pain score noted. Pain was a 10 out of 10 (10 being the highest score in a 1 to 10 scoring for pain) at 2000 hours with 2 mg Morphine IV given. Follow up was greater than 60 minutes at 2130 hours when the patient was still 10 out of 10.
B. On 7/18/16 at 1334 hours 2 mg of oral Dilaudid was given with no follow up until 1600 hours when the patient scored their pain at 5 out of 10. At 1644 hours 2 mg of Dilaudid oral was given and no follow up score/assessment was noted until 2000 hours when the pain score was 7.
C. On 7/21/16 Dilaudid 1 mg was given IV at 2031 hours with no pain level noted (at 1600 hours pain was charted as 5 out of 10) and no follow up documented within 60 minutes.

4. At 1220 hours on 8/23/16, interview with a quality consultant, #55, confirmed that after review of the closed medical record for patient #5, the pain policy was not followed as noted in 3. above for pain level documentation when administering medications and for follow up within the appropriate time frames for the method given as required per facility policies.