HospitalInspections.org

Based on clinical record review, policy and procedure review and interview, it was determined, the Facility failed to follow the established medication administration policy in that three (#14, #16 and #20) of six (#12-#16 and #20) patients' pain was not reassessed within one hour after the administration of PRN (as needed) pain medications. The failed practice did not ensure the effectiveness of the pain medications to relieve the patients' pain. The failed practice had the potential to affect all patients in which pain medication was given. The findings follow:

A. Review of the policy "Inpatient Nursing Pain Assessment" on 07/07/17 revealed "2. Continuing reassessment of pain is conducted at least once a shift during the biophysical assessment according to protocol and a numerical score is assigned to pain with every PRN pain medication and a follow up score, within 1 hour of administration, is documented in the EMR (Electronic Medical Record) to establish the effectiveness of the pain medication." The findings were confirmed in an interview with the Director of Regulatory and Accreditation on 07/07/17 at 1105.

B. Review of Patient #14's clinical record on 07/07/17 revealed pain medication was administered with no evidence of a follow up assessment of the pain within one hour as follows:
1) On 06/29/17 at 1046, 1556, 1747, 1930 and 2031.
2) On 06/30/17 at 0817, 1050, 1215 and 1453.
3) On 07/01/17 at 0420 and 1636.
4) On 07/02/17 at 1629.
5) On 07/03/17 at 0725.
6) The findings were confirmed in an interview with the Instructional Designer on 07/07/17 at 1050.

C. Review of Patient #16's clinical record on 07/07/17 revealed pain medication was administered with no evidence of a follow up assessment of the pain within one hour as follows:
1) On 06/29/17 at 1846, 2013 and 2229.
2) On 07/01/17 at 0813, 1321 and 1604.
3) On 07/02/17 at 1647.
4) On 07/04/17 at 1622.
5) On 07/05/17 at 1332 and 2038.
6) The findings were confirmed in an interview with the Instructional Designer on 07/07/17 at 1115.

D. Review of Patient #20's clinical record on 07/07/17 revealed pain medication was administered with no evidence of a follow up assessment of the pain within one hour as follows:
1) On 07/03/17 at 0350, 0804, 1038, 1421, 1734 and 2143.
2) On 07/04/17 at 0021, 0857 and 1600.
3) The findings were confirmed in an interview with the Instructional Designer on 07/07/17 at 1125.