HospitalInspections.org

Based on review of policy, medical records, the grievance log, and interviews with staff, facility staff failed to identify a grievance and/or send a resolution letter with the required components, including the steps taken to investigate the grievance, for 2 of 5 patient complaints/grievances reviewed. (#3, #8)

The findings include:

Review of a policy titled "Patient Complaints/Grievances" with revision date of 10/2020, revealed "...III. Policy: A. Patient Grievances: A 'patient grievance' is a formal or informal written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) that is made to (Named facility) by a patient, or the patient's authorized representative, regarding the patient's care, alleged abuse or neglect, issues related to (Named facility) compliance with the CMS Hospital Conditions of Participation....8. For each complaint/grievance received by the Patient Relations Department, the Department will: a. Communicate to the patient a projected time of response and an anticipated resolution. All patient complaints/grievances will be answered within a reasonable time frame. In general, patient grievances should be resolved within seven business days, except in cases where data cannot be gathered in that period of time. In cases where resolution does not occur in 7 business days, a written response must be provided to the patient immediately after the 7th business day indicating projected time of response. This should occur every 15 business days until the grievance is resolved....10. Once the investigation is complete, the Patient Relations Department will communicate the resolution of the grievance in writing to the grievant in a language and manner that the patient understands. The written response will include the decision, the name of the grievance investigator, the steps taken to investigate the grievance issues, the results of the grievance process and the date of completion...."

1. Review of a closed medical record on 03/23/2021 revealed Patient #3 was a 75-year-old female admitted from an outside hospital directly to an intensive care unit on 10/05/2020. Review of the record revealed Patient #3 was diagnosed with Stevens Johnson Syndrome (a blistering skin reaction to medication) and experienced multiple medical complications including cardiac arrest on 10/25/2020. Review of the Discharge summary dated 01/06/2021 at 1325 revealed Patient #3 experienced a cardiac arrest during dialysis and expired on 01/06/2021 at 0929.

Review of facility internal documents revealed three grievance files submitted by FM-A (Family Member A) with Patient Relations staff (PRS) beginning on 12/10/2020.

A. Review of Grievance File A revealed beginning 12/10/2020 FM-A stated that CM was "avoiding her and not returning her calls. She states it is not fair that se (sic) has taken sides with ..." FM-B. On 12/10/2020 at 1605, CM " ...said that now APS is arranging for FM -B to have temporary guardianship of (Patient #3), and the hospital is going to extend discharge out until as late as 12/31/20 ... this is why FM-A feels CM has 'taken her (family member's) side'." Review revealed PRS documented at 1711 " ...While I am glad to help settle root issues ...I will not be able to keep talking with (FM-A)..." Review revealed on 12/23/2020 at 1615, "FM-A called back and said she was never told by anyone that she cannot visit anymore, but indicated she cannot ..." and at 1646, " ...I see (FM -B) listed for visitation, but not (FM-A) ...Could someone clarify this with (FM-A) ...?" A 12/23/2020 note at 1705 indicated conversation with a nurse manager (NM) for the inpatient unit where Patient #3 was receiving care stated, " ...FM-A was very disruptive with calls, and we currently have only FM-B allowed for visitation ..." Review of a note dated 01/07/2021 at 1421 revealed, "FM-A stated that her mother passed away yesterday, and 'the counsellor' told FM-A her name was always on the visitation list and she could have visited any time she wanted to ...I apologized for the confusion and tried to get clarification. I told FM-A that her name was not listed for visitation when I last spoke with her, which was 12/23 ..." Review of notes dated 01/13/2021 revealed staff continued to discuss FM-A's ability to visit prior to Patient #3's death but there was no indication that a facility letter had been provided to FM-A with the steps taken to address the grievance concerns.

B. Review of a grievance dated 01/28/2021 revealed FM-A "...again wanted to discuss why her name was removed from the visitation list, something we have discussed multiple times... she again asked who removed her name from the visitation list, and I told her the message I received from the nurse manager said, 'We removed her from the list,' and I explained the reason for it ...so that staff could have some notification to visit. I told FM-A that I could not say whether that means they would have allowed her to visit ..." Grievance file review revealed a letter to FM-A dated 02/02/2021. Review revealed the letter stated FM-A had been " ...disruptive to nurses attempting to carry out their duties ...As I said on the phone, I am not familiar with that incident or any specific dates or details that led nursing leadership to remove your name from the visitation list ...". Review revealed there was no description of the steps taken to investigate the grievance.

C. Review of another grievance dated 02/12/2021 revealed FM-A had contacted the facility's Executive Office with her concerns about Patient #3's care during the hospitalization and "she's been working with (PRS) but the situation isn't being resolved ....She believes her rights were violated for denying her access to (Patient #3) in her final stage of life." Review revealed PRS contacted FM-A by telephone on 02/15/2021 at 1527 and emailed her a request for "a statement detailing your concerns and any requests you have related to these issues ...Like I mentioned on the phone, I will gladly share your email with appropriate hospital leadership..." Review revealed there was no evidence of a written response to the grievance.

Telephone interview on 03/29/2021 at 1330 with the Manager of Patient Relations (MPR) revealed the December 10, 2020 case had been opened as a complaint but should have been turned into a grievance if not immediately resolved. During review of the three cases, the MPR indicated each of the three cases should have been opened as grievances and reviewed per policy. Interview revealed the facility policy was not followed.


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2. Medical record review revealed Patient #8 arrived to the Emergency Department (ED) on 02/04/2021 at 2053. Review of a Triage Note, at 2130, indicated "...Pt (Patient) stating she has hx (history) of sickle cell (chronic red blood cell disease which can cause acute painful crisis and require hospitalization) and believes she is at the beginning of a pain crisis. ..." ED Timeline review revealed report was given to the inpatient unit on 02/05/2021 at 0349 and Patient #8 was transferred to the inpatient unit. An RN note at 0634 indicated "...Patient came to the unit very impatient & insistent on immediate care and pca (Patient controlled analgesia - for pain) hook up. Once pca took longer than what she considers and (sic) acceptable time....she stated she felt neglected and unheard. Patient still was unsatisfied once pca was delivered. All orders were carried out for shift, there is/was nothing left medically to provide for patient at current time. Patient has been to (hospital initials) numerous times and is very familiar with ED and admission process. ..." Review of the Discharge Summary, dated 02/06/2021 at 1107, revealed Patient #8's discharge diagnosis was "...Hemoglobin SS (Sickle Cell Anemia) pain crisis" and noted the patient "...presented with pain typical of her crises. She had pain in her fingers, hips, and knees. She initially also had some chest pain, but this quickly resolved. ..." Review revealed Patient #8 discharged home 02/06/2021.

Review of a Patient Complaint file summary, entered date 02/05/2021, revealed "...(Patient #8's name) left a voicemail at 5:24 AM on 2/5/2021 to express her complaints with the treatment she has received in the ED and from the nursing staff. She said that she felt neglected and mistreated while she was waiting in the ED. When she finally got admitted, the nursing staff was very hostile and have not informed her physician that she would like to speak. She requested pain medication, but since she has been unable to speak with her physician she has not had a conversation about it ..." File review revealed an e-mail was sent to a Nurse Manager on 02/05/2021 at 0834 with a note which stated "...Could you please follow-up with this patient... ." At 1217, file review revealed an e-mail from a Nurse Manager that noted "...She got up here around 3am and she was in pain. She had had a conversation with the admitting doctor in the ED about not being on the PCA yet. The doctor on floor told her to just have RN on floor page them for additional meds if she didn't have PCA. She asked her RN....to call the doctor. (RN name) declined....She felt (RN name) was dismissive of her concerns and argumentative with her. Then.... between the hours of 0300 and 0600, (the patient) called multiple times on the call bell to get (RN name) back to the room. She spoke with our NA.... several times. (Patient #8) said (NA name) was very hostile to her, argued with her, told her she wasn't special.... (Patient #8) asked for her call to be escalated....said she repeatedly asked for her RN, a charge RN, or a House Supervisor to come speak with her.....I apologized for all of her concerns and noted that this was not the expected treatment she should receive on the unit....(Patient #8) said she felt better after talking to me, but that the treatment was so bad, that she would like to escalate further. I assured her that she was heard by me and that I would be documenting her side of the story and sending it to Patient Relations. I assured her I would be reaching out to (staff names) for their version of the story after I shared the patient's perspective with them. (Patient #8) said that she wanted to talk to someone over me. I said there was someone over me, but that person wouldn't be available for her to speak to until I at least had a chance to follow up with my employees and do an investigation. If then necessary, I could involve my Director. I told her that she could escalate through Patient Relations....and provide a written statement of her experiences once she goes home. She said she feels like Patient Relations does nothing and she didn't want this to stay within and be handled by (Hospital initials). She said she may get a lawyer or go to the news, that's how bad it was. I told her it is up to her how she escalates it, she does have the right to, I reiterated what actions I was going to take and that I could check in with her again on Monday. She said she is going home this afternoon. I told her to call Patient Relations again if she wants to discuss escalation options or how she could get back in touch by writing if she chooses to once she gets home....I'll ask for written statements from my employees and send on any other information I receive. ..." File review did not reveal a resolution letter to Patient #8. File review did not indicate the issue was resolved at the time.

Telephone interview with the Manager of Patient Relations on 03/29/2021 at 1455 revealed that sometimes if nursing was going to handle the situation patients would not get follow-up. Interview revealed if the manager had not had time to follow-up prior to discharge of a patient, it would be fair to say it was a grievance and the grievance policy was not followed.

Based on policy and procedure review, medical record review and interviews, the nursing staff failed to supervise and evaluate the nursing care for each patient, by failing to ensure cardiac monitor strips were documented and placed on the patient's medical record for 9 of 25 current Medical Intensive Care Unit (MICU) patients reviewed (Patients [Pts] #47, #40, #39, #44, #43, #45, #42, #46 and #41) and failed to assess/reassess pain per hospital policy for 2 of 8 records reviewed for pain (Pt #6, #8).

Findings Include:

A. Review of the policy and procedure titled "Adult Cardiac Monitoring" effective date 03/2019 revealed "... V. Protocol ... C. Adult RN-assessed ECG (electrocardiogram) Monitoring ...1. Assessment *Obtain a baseline rhythm strip upon arrival to unit and at the beginning of each shift ... 6. Document *In electronic medical record ... *On rhythm strips include: patient's name, date, time, lead, PR interval, QRS interval, QTc or QT interval, and rhythm interpretation."

Review of the policy and procedure titled "Adult ICU Patient" effective date 08/2019 revealed "... IV. Protocol A. Assessment ... 3. Interpret ECG rhythm upon admission and then every 4 hours ... G. Documentation *Document in the patient's medical record *assessment findings ... *active nursing protocols."

1. Review on 03/26/2021 at 1430 of the medical record for Patient #47 revealed a 54-year-old male admitted on 03/12/2021. Review of the medical record revealed no available documentation of an admission cardiac monitor strip. Review of the medical record revealed documentation of only one (1) daily shift cardiac monitor strip from 03/12/2021 through dayshift on 03/26/2021 (15 days).

Interview on 03/25/2021 at 1355 with Nurse Manager #1 revealed a cardiac monitor strip should be printed upon admission, every 12 hours at the beginning of each shift and when a patient's condition warrants. Interview revealed the monitor strips should be initialed and signed after documenting the patient's name, date, time, lead, PR interval, QRS interval, QTc or QT interval, and rhythm interpretation. Interview revealed the monitor strip should be placed in the patient's paper chart, located outside the patient's room door. Interview revealed medical records department should remove the strips from the paper chart daily and scan into the electronic medical record.

Interview on 03/26/2021 at 1600 with Director #1 revealed the nursing staff were expected to document a cardiac monitor strip on admission and daily at the beginning of each shift (7A and 7P). Interview revealed the nursing staff failed to follow the hospital policy.

2. Review on 03/26/2021 at 1430 of the medical record for Patient #40 revealed a 78-year-old female admitted on 03/17/2021. Review of the medical record revealed no available documentation of an admission cardiac monitor strip. Review of the medical record revealed no available documentation of a daily shift cardiac monitor strip from 03/17/2021 through dayshift on 03/26/2021 (10 days).

Interview on 03/25/2021 at 1355 with Nurse Manager #1 revealed a cardiac monitor strip should be printed upon admission, every 12 hours at the beginning of each shift and when a patient's condition warrants. Interview revealed the monitor strips should be initialed and signed after documenting the patient's name, date, time, lead, PR interval, QRS interval, QTc or QT interval, and rhythm interpretation. Interview revealed the monitor strip should be placed in the patient's paper chart, located outside the patient's room door. Interview revealed medical records department should remove the strips from the paper chart daily and scan into the electronic medical record.

Interview on 03/26/2021 at 1600 with Director #1 revealed the nursing staff were expected to document a cardiac monitor strip on admission and daily at the beginning of each shift (7A and 7P). Interview revealed the nursing staff failed to follow the hospital policy.

3. Review on 03/26/2021 at 1430 of the medical record for Patient #39 revealed a 53-year-old female admitted on 03/18/2021. Review of the medical record revealed no available documentation of an admission cardiac monitor strip. Review of the medical record revealed no available documentation of a daily shift cardiac monitor strip from 03/18/2021 through dayshift on 03/26/2021 (9 days).

Interview on 03/25/2021 at 1355 with Nurse Manager #1 revealed a cardiac monitor strip should be printed upon admission, every 12 hours at the beginning of each shift and when a patient's condition warrants. Interview revealed the monitor strips should be initialed and signed after documenting the patient's name, date, time, lead, PR interval, QRS interval, QTc or QT interval, and rhythm interpretation. Interview revealed the monitor strip should be placed in the patient's paper chart, located outside the patient's room door. Interview revealed medical records department should remove the strips from the paper chart daily and scan into the electronic medical record.

Interview on 03/26/2021 at 1600 with Director #1 revealed the nursing staff were expected to document a cardiac monitor strip on admission and daily at the beginning of each shift (7A and 7P). Interview revealed the nursing staff failed to follow the hospital policy.

4. Review on 03/26/2021 at 1430 of the medical record for Patient #44 revealed a 68-year-old male admitted on 03/19/2021. Review of the medical record revealed no available documentation of an admission cardiac monitor strip. Review of the medical record revealed documentation of only one (1) daily shift cardiac monitor strip from 03/19/2021 through dayshift on 03/26/2021 (8 days).

Interview on 03/25/2021 at 1355 with Nurse Manager #1 revealed a cardiac monitor strip should be printed upon admission, every 12 hours at the beginning of each shift and when a patient's condition warrants. Interview revealed the monitor strips should be initialed and signed after documenting the patient's name, date, time, lead, PR interval, QRS interval, QTc or QT interval, and rhythm interpretation. Interview revealed the monitor strip should be placed in the patient's paper chart, located outside the patient's room door. Interview revealed medical records department should remove the strips from the paper chart daily and scan into the electronic medical record.

Interview on 03/26/2021 at 1600 with Director #1 revealed the nursing staff were expected to document a cardiac monitor strip on admission and daily at the beginning of each shift (7A and 7P). Interview revealed the nursing staff failed to follow the hospital policy.

5. Review on 03/26/2021 at 1430 of the medical record for Patient #43 revealed a 61-year-old male admitted on 03/21/2021. Review of the medical record revealed no available documentation of an admission cardiac monitor strip. Review of the medical record revealed no available documentation of a daily shift cardiac monitor strip from 03/21/2021 through dayshift on 03/26/2021 (6 days).

Interview on 03/25/2021 at 1355 with Nurse Manager #1 revealed a cardiac monitor strip should be printed upon admission, every 12 hours at the beginning of each shift and when a patient's condition warrants. Interview revealed the monitor strips should be initialed and signed after documenting the patient's name, date, time, lead, PR interval, QRS interval, QTc or QT interval, and rhythm interpretation. Interview revealed the monitor strip should be placed in the patient's paper chart, located outside the patient's room door. Interview revealed medical records department should remove the strips from the paper chart daily and scan into the electronic medical record.

Interview on 03/26/2021 at 1600 with Director #1 revealed the nursing staff were expected to document a cardiac monitor strip on admission and daily at the beginning of each shift (7A and 7P). Interview revealed the nursing staff failed to follow the hospital policy.

6. Review on 03/26/2021 at 1430 of the medical record for Patient #45 revealed a 44-year-old male admitted on 03/23/2021. Review of the medical record revealed no available documentation of an admission cardiac monitor strip. Review of the medical record revealed no available documentation of a daily shift cardiac monitor strip from 03/23/2021 through dayshift on 03/26/2021 (4 days).

Interview on 03/25/2021 at 1355 with Nurse Manager #1 revealed a cardiac monitor strip should be printed upon admission, every 12 hours at the beginning of each shift and when a patient's condition warrants. Interview revealed the monitor strips should be initialed and signed after documenting the patient's name, date, time, lead, PR interval, QRS interval, QTc or QT interval, and rhythm interpretation. Interview revealed the monitor strip should be placed in the patient's paper chart, located outside the patient's room door. Interview revealed medical records department should remove the strips from the paper chart daily and scan into the electronic medical record.

Interview on 03/26/2021 at 1600 with Director #1 revealed the nursing staff were expected to document a cardiac monitor strip on admission and daily at the beginning of each shift (7A and 7P). Interview revealed the nursing staff failed to follow the hospital policy.

7. Review on 03/26/2021 at 1430 of the medical record for Patient #42 revealed a 66-year-old male admitted on 03/25/2021. Review of the medical record revealed no available documentation of an admission cardiac monitor strip. Review of the medical record revealed no available documentation of a daily shift cardiac monitor strip from 03/25/2021 through dayshift on 03/26/2021 (2 days).

Interview on 03/25/2021 at 1355 with Nurse Manager #1 revealed a cardiac monitor strip should be printed upon admission, every 12 hours at the beginning of each shift and when a patient's condition warrants. Interview revealed the monitor strips should be initialed and signed after documenting the patient's name, date, time, lead, PR interval, QRS interval, QTc or QT interval, and rhythm interpretation. Interview revealed the monitor strip should be placed in the patient's paper chart, located outside the patient's room door. Interview revealed medical records department should remove the strips from the paper chart daily and scan into the electronic medical record.

Interview on 03/26/2021 at 1600 with Director #1 revealed the nursing staff were expected to document a cardiac monitor strip on admission and daily at the beginning of each shift (7A and 7P). Interview revealed the nursing staff failed to follow the hospital policy.

8. Review on 03/26/2021 at 1430 of the medical record for Patient #46 revealed a 56-year-old male admitted on 03/26/2021. Review of the medical record revealed no available documentation of an admission cardiac monitor strip. Review of the medical record revealed no available documentation of the daily shift cardiac monitor strip on 03/26/2021.

Interview on 03/25/2021 at 1355 with Nurse Manager #1 revealed a cardiac monitor strip should be printed upon admission, every 12 hours at the beginning of each shift and when a patient's condition warrants. Interview revealed the monitor strips should be initialed and signed after documenting the patient's name, date, time, lead, PR interval, QRS interval, QTc or QT interval, and rhythm interpretation. Interview revealed the monitor strip should be placed in the patient's paper chart, located outside the patient's room door. Interview revealed medical records department should remove the strips from the paper chart daily and scan into the electronic medical record.

Interview on 03/26/2021 at 1600 with Director #1 revealed the nursing staff were expected to document a cardiac monitor strip on admission and daily at the beginning of each shift (7A and 7P). Interview revealed the nursing staff failed to follow the hospital policy.

9. Review on 03/26/2021 at 1430 of the medical record for Patient #41 revealed a 61-year-old male admitted on 03/26/2021. Review of the medical record revealed no available documentation of an admission cardiac monitor strip.

Interview on 03/25/2021 at 1355 with Nurse Manager #1 revealed a cardiac monitor strip should be printed upon admission, every 12 hours at the beginning of each shift and when a patient's condition warrants. Interview revealed the monitor strips should be initialed and signed after documenting the patient's name, date, time, lead, PR interval, QRS interval, QTc or QT interval, and rhythm interpretation. Interview revealed the monitor strip should be placed in the patient's paper chart, located outside the patient's room door. Interview revealed medical records department should remove the strips from the paper chart daily and scan into the electronic medical record.

Interview on 03/26/2021 at 1600 with Director #1 revealed the nursing staff were expected to document a cardiac monitor strip on admission and daily at the beginning of each shift (7A and 7P). Interview revealed the nursing staff failed to follow the hospital policy.

B.1. Review of the policy and procedure titled "Pain Management" effective date 02/2017 revealed "... III. Policy/Procedure ... 2. Assessment/Management a. All patients will be assessed for the presence/absence of pain at the time of admission or presentation for care ... using an objective rating scale that is specified for each patient. ..."

Review on 03/23/2021 of the medical record for Patient #6 revealed a 69-year-old female presented to the Emergency Department on 02/13/2020 at 1435 with a chief complaint of fall. Review of the medical record revealed nursing triage initiated at 1437. Review of the triage vital signs revealed temperature 98.2, heart rate 58, blood pressure 176/69 and oxygen saturation 100% on room air. Vital signs documented at 1508 revealed no documentation of respirations and no documentation of a pain assessment. Review of vital signs documented at 1653 revealed heart rate 62, respirations 18, blood pressure 158/91 and oxygen saturation of 99% on room air. Vital signs documented at 1653 revealed no documentation of a pain assessment. Review of vital signs documented at 1741 revealed heart rate 69, respirations 18, blood pressure 168/70 and oxygen saturation of 99% on room air. Vital signs assessment documented at 1741 revealed no documentation of a pain assessment. Review of vital signs documented at 1900 revealed blood pressure 148/88. Vital signs assessment documented at 1900 revealed no documentation of a pain assessment. Review of nursing rounding note documented on 02/13/2020 a 1915 revealed "Patient rounds completed. The following patient needs were addressed: Pain..." Review of nursing notes documented at 1915 revealed a pain assessment with complaints of right hand and leg pain with a pain score of "8" (1st pain score documented since arrival 4 hours and 38 minutes earlier) on a scale of 0-10 (0-being no pain, 10-being worst pain). Review of the pain intervention and reassessment revealed Patient #6 received medication and the Provider was notified. Review of nursing notes documented at 2015 revealed a pain assessment with complaints of right hand and leg pain with a pain score of "8". Review of the pain intervention and reassessment revealed Patient #6 received medication and was repositioned. Review of nursing notes documented at 2115 revealed a pain assessment with complaints of right hand and leg pain with a pain score of "8". Review of the pain intervention and reassessment revealed Patient #6 received emotional support and was repositioned. Review of the medical record revealed Patient #6 was discharged home via wheelchair with family. Review of the medical record revealed no available documentation of pain medications administered to Patient #6 prior to discharge at 2137. Review of the medical record revealed no documentation of a pain assessment upon presentation for care to the Emergency Department.

Interview on 03/25/2021 at 1414 with RN #3 revealed Patient #6's pain should have been assessed in triage or by the nurse assuming care of the patient from the ambulance staff. Interview revealed RN #3 had reviewed the medical record for Patient #6 and was unable to locate a pain assessment upon presentation for care. Interview revealed RN #3 was unable to locate any documented pain interventions in Patient #6's medical record. Interview revealed the nursing staff failed to follow the hospital policy.


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B.2. Review of a policy and procedure titled "Pain Management", effective date 10/2020, revealed "... C. Policy 1. Pain Assessment A. Patients are assessed for the presence of pain with an appropriate pain assessment tool at the following times....2. Immediately prior to administration of a PRN (as needed) pharmacologic or non-pharmacologic intervention to reduce pain. 3. Within 5 to 60 minutes after administration of a pharmacologic or non-pharmacologic intervention to reduce pain....If the patient is sleeping at time of reassessment, 'Patient Sleeping' may be documented in lieu of a pain score....4. Other instances that warrant assessment/reassessment of patient pain: i. At time of hospital admission. ..."

Medical record review, on 03/23/2021, revealed Patient #8 arrived to the Emergency Department (ED) on 02/04/2021 at 2053 with a chief complaint of Sickle Cell Crisis (red blood disease disorder which can cause acute painful crisis). Triage Note review, at 2130, revealed the patient believed she was at the beginning of a sickle cell pain crisis with ankles, knees, hips and fingers all hurting. ED record review revealed Roxicodone for pain was administered to Patient #8 on 02/05/2021 at 0017 at which time a pain score of 7 (on a scale of 0-10, with 10 indicating the worst pain ever) was documented. Record review did not reveal evidence of a pain reassessment per policy after the medication. Review revealed Dilaudid 1 mg (pain medication) was administered at 0132 and Oxycodone (pain medication) 10 mg orally was administered at 0245. Record review did not reveal indication of pain assessments or reassessments noted at the time of administration or within 60 minutes after administration. Record review revealed Patient #8 was transported to an inpatient unit, arriving at approximately 0409. Review did not reveal a pain score at the time of transfer from the ED or arrival to the inpatient unit. Review revealed Toradol (for pain) 15 mg IV (intravenously) was administered at 0427. Review of the record did not reveal documentation of a pain assessment/ reassessment at the time of medication administration or within 60 minutes after administration. Record review showed the next pain assessment documented was on 02/05/2021 at 0900.

Telephone interview with RN #5 on 03/25/2021 at 1000 revealed the RN cared for Patient #8 on the inpatient unit. The RN stated pain assessments were generally done within an hour of admission to the inpatient unit and before and after administration of prn pain medications. Interview revealed the RN recalled asking about pain and stated there should have been pain scores noted in the record.

Telephone interview with RN #6 on 03/26/2021 at 0910, the ED RN who cared for Patient #8, revealed the RN did not recall medications given to this patient but would generally follow-up with patients after giving pain medication. The RN stated pain was what the patient "came in for". Interview revealed RN #6 did not recall pain scores but would have recorded what the patient told her.

Interview with NM #7, the Nurse Manager for Patient #8's inpatient unit, revealed a pain assessment should be done with the initial nursing assessment and there should have been a pain score when pain medication was given. Interview revealed there was no documentation available to indicate policy was followed.

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