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Based on record review and interview the facility failed to include the patient in the implementation of the patient's pain management plan in one of one chart reviewed. (ID# 1)

Findings include:

Medical record review of patient's (ID#1) medical record revealed that on 5/5/2016 the patient received pain medication five (5) times without a pain scale documented or re-evaluated within an hour after administration. At 1007 hydrocodone-acetaminophen (Norco) 5-325 milligram one tablet was given, at 1106 Morphine 4 milligrams were administered intravenously, at 1357 one tramadol 50-100 milligram tablet was given, at 1543 hydrocodone-acetaminophen (Norco) 5-325 milligram one tablet was given and at 1749 Morphine 4 milligrams were administered intravenously. The patient was discharged at 1844.

Interview with quality personnel (ID# 53) on 5/20/18 at 1205 PM stated that the pain scale should be documented to administer the appropriate ordered medication and the pain should be re-evaluated within an hour of administration to acknowledge its effectiveness.

Facility policy titled: Pain Management states the following:
Policy:
B. The right of patients to have their pain assessed and managed will be recognized.
F. The patient's pain score will be used to determine the analgesic and/or dose selected.
2. Frequency of Pain Assessments
b. Prior to Administration of a Pain Medication
i. Prior to the administration of each scheduled or PRN pain medication, a pain score and location will be documented. Based on nursing judgement a more detailed pain assessment may be performed.
c. Reassessment Frequency
ii. Pain reassessment will be performed after the administration of a schedules or PRN medication, when there has been a change in patient condition and as part of the discharge process.
iii. Documentation of the effectiveness of the pain medication or pain intervention will occur within one (1) hour of intervention.