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Based on document review and interview, it was determined that for 2 of 4 patients' (Pt. #1 and Pt. #2) clinical records reviewed for nursing pain assessments, the Hospital failed to ensure that the registered nurse (RN) evaluated the nursing care for each patient by failing to conduct a pain assessment/reassessment, as required.

Findings include:

1. On 12/6/2022, the clinical record for Pt. #1 was reviewed. On 10/19/2022, Pt. #1 was admitted to the Hospital due to chronic leg wound and sinus tachycardia (fast heart rate):

- On 10/19/2022 at 8:39 AM, the nursing pain assessment indicated that Pt. #1's pain score was 7 (severe pain). At 8:39 AM. Pt. #1 was given Dilaudid (pain medication) .5 mg intravenous (IV). At 8:41 AM, Pt. #1's pain score was still 7 (dissatisfied). At 11:43 AM, a pain reassessment was conducted (approximately 3 hours after administration of Dilaudid IV pain medication).
- On 10/19/2022 at 1:07 PM, the nursing pain assessment indicated that Pt. #1's pain score was 7. At 1:08 PM, Oxycodone (oral pain medication) IR (immediate release) was given to Pt. #1. A pain reassessment was not conducted after the medication intervention.
- On 10/19/2022, when Pt. #1 was admitted to the D2 (Medical-Surgical Unit), a nursing pain assessment was not conducted on admission.

2. On 12/6/2022, the clinical record for Pt #2 was reviewed. Pt #2 was admitted on 11/27/2022, with a diagnosis of generalized weakness. The Physician's Orders from 11/27/2022-12/6/2022, were reviewed and included pain management (Morphine Sulfate and Acetaminophen). Pt #2's Pain Assessments and MAR (Medication Administration Record) were reviewed and included the following:

- On 12/5/2022 at 4:50 AM, Pt #2 was administered Acetaminophen 650 mg (milligrams) oral, for a pain score of 6/10 (10 being the worst). The pain re-assessment was done at 8:00 AM (3 hours and 10 minutes later), not the required 1-hour pain re-assessment for oral medication.
- On 12/6/2022 at 11:56 AM, Pt #2 was administered Morphine Sulfate IV (intravenous) 4 mg for a pain score of 10/10. The pain re-assessment was done at 12:26 PM; the pain score was 9/10; and patient's pain satisfaction was documented as "dissatisfied". The subsequent pain assessment was done on 12/6/2022 at 3:53 PM (3 hours and 27 minutes later).

3. On 12/7/2022, the Hospital's policy titled, "Pain Management" (effective 3/25/2022) was reviewed and included, "...I... To provide guidelines on the appropriate assessment and management of the physical and psychological symptoms associated with pain... V...A...1. Comprehensive Pain Assessment... by a Registered Nurse, unless pain yields 0, at the following times: 1... a. On admission... 5. Pain Reassessment: a. Pain is reassessed after intervention is provided... d. If pain is not an acceptable level, and intervention is intended to improve comfort, reassessment should generally be performed using the following guidelines: i. IV (intravenous) medication - reassess at approximately 30 minutes. ii. PO medication - reassess at approximately 60 minutes..."

4. On 12/7/2022 at approximately 12:00 PM, findings were discussed with E #5 (Nurse Educator/Computer Navigator). E #5 stated that nursing pain assessment should be conducted when a patient is admitted on the unit. E #5 added that reassessments should also be conducted at least 30 minutes after administration of intravenous pain medication and an hour after for oral pain medication.

Based on document review and interview, it was determined that for 2 of 4 patients' (Pt. #1 and Pt. #4) clinical records reviewed regarding blood transfusions, the Hospital failed to ensure that vital signs were performed in accordance with the approved staff policies and procedures.

Findings include:

1. On 12/7/2022, the Hospital's policy titled, "Blood Administration" (effective 6/2021) was reviewed and included, "... Appendix L. Monitoring the Recipient during Transfusion. A. All patients must be observed during and after blood component transfusions for signs and symptoms of transfusion reaction... C. Minimally, vital signs must be monitored and documented as defined below... All blood products... at 15 minutes after the start of the transfusion, within 60 minutes after completion of the transfusion..."

2. On 12/7/2022, the clinical record for Pt. #1 was reviewed. On 10/19/2022, Pt. #1 was admitted to the Hospital due to chronic leg wound and sinus tachycardia (fast heart rate):

- On 10/19/2022 at 2:33 PM, a RN started a transfusion of a unit of platelet (a blood component that prevents bleeding) for Pt. #1. The transfusion was completed at 3:45 PM. Pt. #1's temperature was not taken 15 minutes after the start of the transfusion.

- On 10/22/2022 at 7:06 PM, a RN started a transfusion of a unit of platelet for Pt. #1 Pt. #1. The transfusion was completed at 8:26 PM. Pt. #1's vital signs were not taken 15 minutes after the start of the transfusion.

3. On 12/7/2022, the clinical record for Pt #4 was reviewed. Pt #4 was admitted on 12/1/2022 with a diagnosis of anemia. The Physician's Orders from 12/1/2022-12/7/2022, were reviewed an included an order (dated 12/1/2022) to transfuse 4 units of RBC's. Pt #4's vital signs monitoring and blood transfusion assessments were reviewed and included the following:

- On 12/1/2022 at 1649 (4:49 PM), Pt #4's blood transfusion for RBC's was initiated. The next set of vital signs were documented at 1822 (6:22 PM) (1 hour and 33 minutes later).

4. On 12/7/2022 at approximately 12:00 PM, findings were discussed with E #5 (RN/Nurse Educator/Computer Navigator). E #5 stated that vital signs monitoring should be conducted 60 minutes before, 15 minutes after initiation, and 60 minutes after completion of the transfusion. E #5 stated that vital signs monitoring included blood pressure, heart rate, respiratory rate, and temperature.