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LAUREATE PSYCHIATRIC CLINIC AND HOSPITAL, INC
CONTENT OF RECORD
Tag No.: A0449
Based on record review and interview, the hospital failed to ensure documentation of reassessment of pain for one (Patient #1) of eight patients.
This failed practice has the likelihood to result in the patient not receiving therapeutic treatment.
Review of a facility policy titled, "Pain Management," read in part, "Pain reassessment is an ongoing...process. The reassessment time interval guideline for pharmacological intervention is 60 minutes...Documentation in the patient's medical record should include...all pain assessments, including...reassessments."
Patient #1
Review of the medication administration report showed acetaminophen was administered for pain on 01/26/20 and no documented reassessment of pain after the medication was administered.
On 01/28/20 at 10:11 AM, Staff F reviewed the medical record for Patient #1 and stated there was no post pain assessment for the medication administration.
CONTENT OF RECORD: ORDERS,NOTES,REPORTS
Tag No.: A0467
Based on record review and interview, the hospital failed to ensure completion of lab draws for one (Patient #2) of eight patients.
This failed practice has the likelihood to result in poor patient outcomes and place patients at risk of unidentified health conditions, and incomplete health information necessary for diagnosis and treatment.
Patient #2
Review of the medical record showed no lab results for "TSH with FT4 if Indicated" and "Folate Level" orders dated 11/14/19.
On 01/28/19 at 12:05 PM, Staff F reviewed the medical record and stated the TSH with FT4 if indicated and Folate level labs were not drawn.