HospitalInspections.org

Based on policy review, medical record review, and interview, the facility failed to ensure facility staff assessed surgical incision sites and pain management effectiveness for 1 of 4 (Patient #4) sampled patients.

The findings included:

1. Review of the facility policy titled, "Pain Management Guideline" showed, "...A comprehensive pain assessment is conducted as appropriate to the patient's condition and the scope of care, treatment and services provided...The patient's pain status is assessed, but not limited to...Each complaint of pain...When pain medication or dosage is changed...When pain interventions are provided...Reassessments of intervention effectiveness occurs based on type/route of medication, method of pain management, and as patient condition requires. The reassessment is documented...The nurse continues to intervene until an acceptable level of pain is obtained as determined collaboratively by the patient, family and caregiver..."

2. Medical record review for Patient #4 showed an admission date of 3/5/2020 with diagnoses that included Severe Mitral Valve Prolapse. Patient #4 underwent an elective procedure to improve the function of her mitral valve on 3/5/2020.

Review of the Flowsheet Data report dated 3/5/2020 showed Patient #4 had an incision site that was assessed at 2:30 PM, 3:41 PM, 4:30 PM, and 6:35 PM. There was no documentation the incision site was assessed by a nurse for the remainder of her hospital stay.

Review of the Medication Administration Record (MAR) showed Patient #4 was administered Morphine 2 milligrams (mg) intravenously (IV) on 3/5/2020 at 9:39 PM, and again on 3/6/2020 at 12:18 AM. There was no documentation in the medical record that a pain reassessment had been performed to determine the effectiveness of the intervention.

In an interview on 3/17/2020 at 9:30 AM, the Director of Risk Management verified the assessments weren't performed.