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Based on record review, policy review, and staff interview, it was determined the facility failed to document the assessment and reassessment of pain for two (#1, #2) of 10 sampled patients in compliance with facility policies. This practice does not ensure effective assessment, reassessment and communication of nursing interventions and the patient response to the individualized plan of care.

Findings include:

1. The Facesheet indicated Patient #1 was admitted on 10/11/12 at 10:03 p.m. with an admitting diagnosis of rectal pain and rectal prolapse.

The Assessment Flow Sheet and Medication Administration Record (MAR) were reviewed 11/20/2012 at approximately 11:30 a.m. The MAR indicated the patient was given Dilaudid (medication for pain) 1 mg intravenously (IV) on 10/12/12 at 2:42 a.m., 8:04 a.m., 1:46 p.m., and 7:42 p.m. The Assessment Flow Sheet indicated the documentation of the assessment of the patient's pain was recorded one time on 10/12/12 at 7:34 a.m. as 0 on a scale of 0-10 indicating the patient had no pain at that time.

The MAR documented the patient was given Dilaudid 1 mg IV on 10/13/12 at 4:58 a.m., 1:10 p.m., and 7:26 p.m.. The Assessment Flow Sheet indicated the documentation of the assessment of the patient's pain was recorded one time on 10/13/12 at 9:45 p.m. as 6 on a scale of 0-10.

The MAR documented the patient was given Dilaudid 1 mg IV on 10/14/12 at 5:08 a.m., 11:20 a.m., and 5:26 p.m. She was given Dilaudid 0.5 mg IV at 9:32 p.m. The Assessment Flow Sheet indicated the documentation of the assessment of the patient's pain was recorded one time on 10/14/12 at 7:43 p.m. as 3 on a scale of 0-10.

The MAR documented the patient was given Dilaudid 0.5 mg IV on 10/15/12 at 1:37 a.m., 5:52 a.m., 10:26 a.m., 3:11 p.m., and 6:55 p.m. The Assessment Flow Sheet indicated the documentation of the assessment of the patient's pain was recorded on 10/15/12 at 10:20 a.m. as 4 on a scale of 0-10; at 11:26 a.m. as 4; at 4:11 p.m. as 4; and at 10:21 p.m. as 4.

The MAR documented the patient was given Dilaudid 0.5 mg IV on 10/16/12 at 1:26 a.m., 5:28 a.m., 9:53 a.m., and 1:49 p.m. The Assessment Flow Sheet indicated the documentation of the assessment of the patient's pain was recorded one time on 10/16/12 at 8:17 a.m. as 3 on a scale of 0-10.

Policy Number 100.185.86, Pain Management, effective 10/2010, was reviewed on 11/20/12 at approximately 11:00 a.m. The Assessment Procedure indicated all patients will be initially assessed for the presence or absence of pain and the assessment will include documentation of the measure of pain intensity and a measure of pain relief. The policy for Reassessment stated the patient's response to pain measures will be reassessed after treatment and documented.

Policy Number 100.185.76, Charting: Adult Clinical Flowsheet , effective 3/2011, Page 3, section 7. Pain Assessment, indicated the nurse was to record pain quality, time pattern and interventions.

An interview and record review was conducted with the Clinical Educator on 11/20/2012 at approximately 2:30 p.m. She confirmed the Assessment Flowsheet was the area of the medical record designated to document pain assessment and reassessment by nurses. A search of the medical record for Patient #1 failed to reveal any additional documentation of pain assessment and reassessment other than that described above. She confirmed the documentation did not reflect assessment of the patient's pain prior to and following interventions as required by facility policy.

2. The medical record of Patient #2 revealed that she was admitted to the facility on 11/19/12 at approximately 12:56 a.m. with a diagnosis of back pain/sciatica.
A physician's order dated 11/20/12 ordered Acetaminophen-oxycodone 10 mg/325 mg 1 tablet by mouth every 4 hours as needed for pain. Review of the MAR revealed the Acetaminophen-oxycodone was administered at 4:15 a.m. There was no documentation indicating the patient's pain level after administration of the medication.
An interview was conducted with the nurse manager at 12:15 p.m. She confirmed there was no follow up for effectiveness of pain medication documented in the medical record. She also confirmed that it is the responsibility of the nurse administering medication to assess pain levels pre and post administration of pain medication.

Based on record review and staff interview it was determined medications were not administered in compliance with the physician plan of care for two (#4, #7) of 10 sampled patients. This practice does not ensure safe and effective medication administration.

Findings include:

1. Patient #4 was admitted on 10/13/12 at 10:55 a.m. with a diagnosis of constipation and rectal pain.

The Physician Order dated 10/13/12 dated 12:20 p.m. revealed an order for Protonix 40 mg orally each morning before breakfast. The Medication Summary revealed the pharmacy scheduled delivery of the medication was scheduled at 7:30 a.m. each day. The Medication Administration Record (MAR) documented the medication was administered on 10/14/12 at 2:41 p.m., approximately seven hours later than the scheduled time. Detailed review of the medical record failed to reveal documentation of the reason the medication was not administered as ordered.

An interview and record review was conducted with the Clinical Educator on 11/20/12 at approximately 2:30 p.m. She confirmed the Protonix was not administered as ordered by the physician.

2. The medical record of patient #7 revealed that she was admitted to the facility on 11/18/12 at approximately 11:48 a.m. with a diagnosis of Abdominal Pain. A physician's order dated 11/18/12 at 4:23 p.m. ordered Morphine 60 mg 2 tablets by mouth every 8 hours. The MAR revealed on 11/18/12 at 5:17 p.m. Morphine 60 mg 2 tabs were administered to patient #7 and were administered again 4 hours later at 9:10 p.m.
An interview was conducted with the Director of Nursing Systems 11/20/12 at approximately 11:00 a.m. She confirmed the nurse did not follow the physician's order when administering the Morphine 60 mg 2 tablets. She confirmed the physician ordered Morphine 60 mg 2 tablets by mouth every 8 hours and not every 4 hours.