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Based on policy review, medical record review and interview, the nursing staff did not document pain reassessment following the administration of analgesics in 4 out of 18 medical records reviewed.

Findings include:

Review of Pain Management Policy, last revised 04/01/17 revealed complete pain reassessments should be within 60 minutes of administering as needed pain medications.

Review of Patient #5 medical record dated 10/16/19 revealed morphine was administered for pain at 01:20 AM and 07:48 AM with no documentation to indicate the patient's pain level was re-assessed within 60 minutes following the administration of morphine.

Review of Patient #11 medical record dated 11/13/19 revealed morphine was administered for pain at 02:29 PM and 05:05 PM with no documentation to indicate the patient's pain level was re-assessed within 60 minutes following the administration of morphine.

Review of Patient #3 medical record dated 01/04/20 revealed pain medication was administered on multiple occasions, with no documentation to indicate the patient's pain level was re-assessed within 60 minutes following the 04:33 AM, 10:32 AM, 01:30 PM, 04:52 PM and 09:21 PM administration of pain medication.

Review of Patient #4 medical record dated 01/02/20 revealed morphine was administered for pain at 11:23 AM and 02:26 PM with no documentation to indicate the patient's pain level was re-assessed within 60 minutes following the administration of morphine.

Interview with Staff (C), RN on 01/29/20 at 11:45 AM revealed staff should reassess pain within an hour of analgesic medication administration.

Interview with Staff (E), RN on 01/29/20 at 11:00 AM verified the above findings.

Based on medical record review, policy review and interview, the Emergency Department (ED) nursing staff did not administer intravenous Cardizem to Patient #1 as ordered by the ED provider and in accordance with facility policy.

Findings include:

Review of ED provider note dated 03/20/19 at 03:19 PM revealed Patient #1 presented to the ED with new onset atrial fibrillation. The plan was to administer intravenous (IV) fluids and start a Cardizem drip to gently titrate rate control.

Review of ED physician orders dated 03/20/19 at 03:26 PM revealed an order for Sodium Chloride intravenous bolus and Cardizem 100mg in 100 mls of Sodium Chloride for infusion.

Review of ED care timeline dated 03/20/19 PM at 03:30 PM revealed Cardizem 100mg in 100ml of Sodium Chloride was hung with the ordered rate noted as 15mls per hour and at 03:40 PM 500 mls of Sodium Chloride for bolus was hung.

Review of the ED provider note dated 03/20/19 at 04:15 PM revealed that the nurse reported that the patient had mistakenly received a bolus of Cardizem 100mg. The patient was monitored and treatment with IV fluids and Calcium Gluconate was implemented, along with intensive care consultation.

Review of policy, Clinical Practice: Medication Procedure: Diltiazem (Cardizem) IV Infusion, last approved 03/06/19 revealed use of IV infusion device for continuous infusion and begin infusion at ordered rate. Initial infusion rate is usually 10mg/hour (range of 5-15 mg/hr.). The maximum rate for Diltiazem is 20 mg/hr.

Interview on 01/30/20 at 02:30 PM with Staff (B), Director of Regulatory verified the above findings.