HospitalInspections.org

Based on record review and interview, the hospital failed to ensure:

· Pain was reassessed after pain medication was given for two (patients # 2 and 7) of 22 records reviewed
· Nausea was reassessed after medication was given for one (patient # 1) of 22 records reviewed

This failed practice has the likelihood to place patients at risk for the inability to achieve optimal relief of pain and nausea.

Findings:

A policy titled MHLC NUR Pain Management read in part, "the pain intensity and relief, as reported by the patient, will be assessed and documented after each pain management intervention and evaluated after a sufficient amount of time has elapsed."

A review of clinical records on Patient #1 and #2 showed no reassessment of pain and Patient #7 no reassessment of nausea after pain and nausea medication was given.

PAIN

· Patient #2 A review of the clinical record showed 7.5-3.25 mg Norco x 2 given on 01/06/20 at 2:43 pm for pain. Documentation showed no reassessment of pain during the remaining shift (4 hours & 17 minutes).

· Patient #7 A review of the clinical record showed 500 mg Tylenol x 1 given on 02/20/20 at 12:40 pm for pain. Documentation showed no reassessment of pain during the remaining shift (6 hours & 20 minutes).

NAUSEA

· Patient #1 A review of the clinical record showed 4 mg Zofran x 1 given on 11/27/19 at 12:43 pm for nausea. Documentation showed no reassessment of nausea during the remaining shift (6 hours & 17 minutes).


On 02/24/20 at 10:55 am, Staff R stated reassessment of pain was not done on Patient #2 and #7 and reassessment of nausea was not done on Patient #1.

On 02/24/20 at 11:33 am, Staff A stated the expectation was for the nurse to reasssess pain within the remaining 12 hour shift after the pain medication was given.

On 02/24/20 at 12:30 pm, Staff W stated the expectation was to a reassess the patient's pain 10 to 15 minutes after pain medication was given intravenously and 20 to 30 minutes after pain medication was given by mouth. Staff W stated each nurse has Staff W's direct phone number to call if pain is not relieved within 30 to 60 minutes and Staff W would change the dose or pain medication.