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PROHEALTH OCONOMOWOC MEMORIAL HOSPITAL
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on record review and interview, the facility failed to ensure that pain reassessments were completed 60 minutes after a pain medication was given per the facilities policy in 3 of 10 patients given pain medication (Patient #6, #7 and #10) in a total of 10 medical records reviewed.
Findings include:
The facility policy titled "Pain Assessment and Management Policy and Procedure" lasted reviewed 3/29/2020 under procedure #11 revealed "Reassess pain within one hour of prn [as needed] pain medication."
Review of Patient #6's medical record revealed Patient #6 presented to the Emergency Department 7/29/2021 at 1:57 PM with abdominal pain. Patient #6 was given morphine 2 mg 9:25 PM. There was no pain reassessment done within 1 hour.
Review of Patient #7's medical record revealed Patient #7 presented to the Emergency Department 7/06/2021 at 1:00 PM with history of abdominal pain. On 7/07/2021 at 9:42 PM, Patient #7 was given Tylenol for pain. There was no pain reassessment done within 1 hour.
Review of Patient #10's medical record revealed Patient #10 presented to the Emergency Department 8/04/2021 at 8:04 PM with diarrhea and gastric distention. On 8/04/2021 at 10:49 PM, Patient #10 was given Tylenol for pain. There was no pain reassessment done within 1 hour.
On 8/24/2021 at 10:24 AM during interview with Clinical Nurse Specialist (CNS) E, CNS E stated "our pain policy does say" reassessment within 1 hour.
On 8/24/2021 at 3:28 PM during interview with Emergency Department Manager O, when asked if there were pain reassessments for prn pain medications given to Patient's #6, #7 and #10, Manager O stated "not that I can see."