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Based on record review and interview, the facility failed to ensure that the nursing staff conducted pain reassessment after pain medication was administered according to hospital policy for 4 (#3, #17, #19, and #21) of 5 sampled patients.


This deficient practice had the likelihood to cause harm in all patients receiving pain medication with no reassessment to evaluate if the pain medication relieved the pain.


Findings include:

Patient #3

A review of the clinical record of Patient #3 revealed he was an 84-year-old man who was admitted on 04/19/2019 with Hypernatremia, dehydration, hypoxia and STEMI (ST evaluation of myocardial infarction).

Patient #3 received Morphine 2 mg intravenous on 4/20/2019 at 00:46 AM; however, there was no reassessment of the pain medication by Staff #13 to know if the patient was relieved of pain. Patient #3's pain scale was 7 of 10 prior to being medicated.

Patient #3 received Morphine 2 mg intravenous on 4/20/2019 at 21:05 (9:05 PM); however, there was no reassessment of the pain medication by Staff #13 to know if the patient was relieved of pain. Patient #3's pain scale was 7 of 10 prior to being medicated.

Patient #3 received Morphine 2 mg intravenous on 4/22/2019 at 1:14 AM; however, there was no reassessment of the pain medication by Staff #13 to know if the patient was relieved of pain. Patient #3's pain scale was 6 of 10 prior to being medicated.


Patient #17

A review of the clinical record of Patient #17 revealed she was admitted on 04/22 /2019 with Extremity pain and swelling with an arterial occlusion.


Patient #17 received Morphine 2 mg intravenous on 4/24/2019 at 2:25 AM; however, there was no reassessment of the pain medication by Staff #13 to know if the patient was relieved of pain. Patient#17's pain scale was 9 of 10 prior to being medicated.

Patient #19

A review of the clinical record of Patient #19 revealed she was admitted on 5/16/2019 with Atrial Fibrillation and Vulvar Cancer.

Patient #19 received Morphine 2 mg intravenous on 5/17/2019 at 3:57 AM; however, there was no reassessment of the pain medication by Staff #13 to know if the patient was relieved of pain. Patient#19's pain scale was 7 of 10 prior to being medicated.


Patient #19 received Morphine 2 mg intravenous on 5/17/2019 at 22:44 (10:44 PM); however, there was no reassessment of the pain medication by Staff #13 to know if the patient was relieved of pain. Patient#19's pain scale was 7 of 10 prior to being medicated.


Patient #21

A review of the clinical record of Patient #21 revealed he was admitted on 6/13/2019 with Chest Pain.

Patient #21 received Morphine 2 mg intravenous on 6/13/2019 at 21:26 (9: 26 PM); however, there was no reassessment of the pain medication by Staff #13 to know if the patient was relieved of pain. Patient#21's pain scale was 8 of 10 prior to being medicated.


Patient #21 received Morphine 2 mg intravenous on 6/14/2019 at 5:30 AM; however, there was no reassessment of the pain medication by Staff #13 to know if the patient was relieved of pain. Patient#21's pain scale was 7 of 10 prior to being medicated.


During the documentation review on the computer with Staff #8 it was flagged in the computer that no pain re-assessment had been completed by Staff #13.

A review of the facility's policy titled, "PAIN MANAGEMENT - CARE OF THE PATIENT WITH PAIN" revealed the following:

"RN/LVN
1. Identify and document pain, including effect and adverse effect of therapy. Assess for intended and unintended effects:
o At regular intervals after starting the pain treatment regimen:
minimally every 4 hours for ongoing pain
o With each report of pain
o At a suitable interval after each pharmacological or nonpharmacological intervention, such as 15-30 minutes after parenteral drug therapy and one hour after oral administration.
o AHCPR Guidelines
2. Monitor the following for patients receiving opioids
A. The frequency and type of monitoring and response of patients will
be based on:
o Age
o Initial response to opioid or higher opioid dose (based on the pharmacology of the agent: See reference chart).
Note: Monitoring of the patient's response, which includes the respiration rate, to the first and second
doses are especially important, as they are the most likely times in which adverse sedative/ respiratory effects may occur."

An interview with Staff #8 on 08/06/2019 at 11:00 AM confirmed that Staff #13 was not documenting pain re-assessments after pain medication (Morphine) was given for pain relief.