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Based on interview and document review, the facility failed to provide re-assessment for the effectiveness of pain medication and failed to perform updates/reassessments of the patient's plan of care. Findings include:

--the facility failed to ensure that nursing staff perform a re-assessment of patients to determine effectiveness of pain medication after administration (see A-395),
---the facility failed to ensure that nursing staff review and update the patient's plan of care per policy (see A-396).

Based on document review and interview, the facility failed to ensure that nursing staff perform a re-assessment for 2 of 2 current inpatients (#6, #8) and 1 of 2 discharged patients (#20) to determine effectiveness of pain medication after administration resulting in the potential for unmet pain control and poor patient outcomes. A total universe of 20 records were reviewed. Findings include:

On 12/08/2014 at 0930, review of the medical record for patient #6 regarding administration and re-assessment of pain medications revealed that the patient was receiving Dilaudid 2 milligrams IVP (intravenous push)PRN (as needed or desired) every 4 hours for pain. The patient was admitted to the hospital on 12/04/2014 for back pain. The nursing documentation shows that the patient complained of pain on 12/04 at 1640 and the RN (Registered Nurse) administered the Dilaudid for a pain rating of 10/10 at 1650. The record documentation does not contain a re-assessment by a RN after the administration. The patient again complained of pain rating it 10/10 at 2145. The RN administered the Dilaudid. The record did not contain a re-assessment. On 12/05/2014 at 0400, 0925, 1430 and 2200 the patient was administered the Dilaudid for pain. The record lacked re-assessments for effectiveness of pain control. The record lacked documentation for re-assessment/effectiveness of the pain medication for all of the administrations for pain medication on 12/06, 12/07, and at 0700 on 12/08.

On 12/08/2014 at 1120, review of the medical record for patient #8 regarding administration and re-assessment of pain medications revealed that the patient was receiving Dilaudid 1 milligram IVP (intravenous push) PRN (as needed or desired) every 4 hours for pain. The patient was admitted to the hospital on 11/30/2014 for a wound infection. The nursing documentation shows that the patient complained of pain on 11/30/2014 at 1450, the RN (Registered Nurse) administered the Dilaudid for a pain rating of 8/10 at 1500. The record documentation does not contain a re-assessment by a RN after the administration. On 12/01/2014 at 1000, patient #6 again complained of pain rating it at 8/10. The RN administered the Dilaudid at 1015. The record does not contain a re-assessment after the administration of pain medication. The patient received the Dilaudid again on 12/01/2014 at 1500, no re-assessment for effectiveness of the pain medication was documented in the record. The patient received Dilaudid for complaints of pain on 12/02 at 0030, 1000, 1400 and 2000, on 12/03 at 0420, 1105, 1800 and 2330, 12/04 at 0615, 1200 and 1845, 12/05 at 0340, 0925 and 1600, on 12/06 at 0330, 0950, 1745 and 2215, on 12/07 at 0730, 1620 and 2200, on 12/08 at 0645. The record lacked documentation for re-assessment/effectiveness of the pain medication for all of the administrations for 12/02, 12/03, 12/04, 12/05, 12/06/ 12/07 and 12/08/2014.

In an interview with staff K on 12/08/2014 at 1115, confirmed that the records did not contain re-assessments after administration of pain medication. When queried if nurses were supposed to complete and document a re-assessment, she stated, "They are." When queried as to how soon after the administration should the nurse be re-assessing the patient, she stated, "It is different for different routes of administration." When queried if it would tell me in the policy, she stated, "It will."

On 12/09/2014 at 0830, review of the medical record for patient #20 revealed that the patient had been admitted on 06/24/2014 for infected decubitus ulcers. The patient was receiving routine pain medications and had an order for PRN Dilaudid 1-2 milligrams IVP (through the IV) for breakthrough pain every 4 hours. On 06/24/2014 at 2007, the RN documented that the patient "Complains of pain/discomfort." Dilaudid 1 milligram was administered IVP. The RN did not document a re-assessment regarding the effectiveness of the medication. On 06/24/2014 at 2331 when queried the patient rated his pain level "10/10" and documentation supports the administration of Dilaudid and Benadryl. The patient's record does not contain a re-assessment of the patient's pain to determine the effectiveness of the pain medication and Benadryl that was administered. On 06/25/2014 at 0003 the patient again complained of pain and rated it "10/10." The RN administered "an additional milligram of pain medication (Dilaudid) per orders, patient is stating that he is having spasms running down his legs, asked patient to wait and see if the Dilaudid will be sufficient for the present. Patient has not allowed any further care at this time." The RN did not document a re-assessment of the effectiveness of the medication. On 06/25/2014 at 0205 the RN documented "Patient was found slumped over sleeping. No distress noted." At 0225, nursing documentation reads, "Patient awakened to ask for pain management. Informed him it would be 4 am till he could receive more. Verified that patient wanted to be left till meds could be given for pain. Abiding." The RN documented on 06/25/2014 at 1415, "Patient is having complaints of pain at this time. Patient was given his home medications including his Methadone and his Morphine. Patient was also medicated with Dilaudid 2 milligrams. The patient's girlfriend stated to the RN, "You people just don't understand, he is in pain even if he isn't answering you or if he isn't awake." The record does not contain a re-assessment for the effectiveness of pain medication administered. On 06/25/2014 at 1617, the RN documented, "Patient's girlfriend came to desk and RN if she could 'bring patient down pain medication.' RN came to the room to let patient know that he was not due for pain medication and patient proceeded to say, 'What good is the hospital then?'"

In an interview with staff B (Chief Nursing Officer) on 12/09/2014 at 1145, he confirmed that patient #20's medical record did not contain re-assessments for the effectiveness of pain medications after administration. Staff B stated, "The nurses are supposed to go back and re-assess the patients."

On 12/09/2014 at 1200, a review of the facility's policy titled, "Pain Management, #106370-00-05, Issued: 08/12/13," read, "Frequency of assessment/reassessment will depend on the severity of the pain and the clinical situation: 1. Pain will be assessed and documented on admission and with any new report of pain ....3. Medical patients-pain will be assessed and documented a minimum of every shift. 4. Pain assessment and reassessment based on mode of pharmacologic administration will be documented as follows: IV -0.5 hours after administration. Oral - 1 hour post administration."

Based on document review and interview, the facility failed to ensure that nursing staff review and update the patient's plan of care per policy for 7 of 9 current inpatients (#1, #2, #4, #5 #6, #7, #8 ) and 11 of 11 discharged patients (#10-#20) resulting in the potential for unmet and unidentified patient needs. A total universe of 20 records were reviewed. Findings include:

On 12/08/2014 between 0915 and 1200, record reviews were conducted for current inpatients during unit tours. The reviews revealed the following:

Patient #1 was admitted to the facility on 11/30/2014. A care plan was initiated on 12/02/2014. The care plan lacked documentation of re-assessments for the AM (morning) shift for 12/06/2014 and 12/07/2014.

Patient #2 was admitted to the facility on 12/02/2014. A care plan was initiated on 12/02/2014. The care plan lacked documentation of re-assessments for the AM shift 12/03, the PM (evening) shift 12/04 and the PM shift on 12/05.

Patient #4 was admitted to the facility on 12/01/2014. A care plan was initiated on 12/01/2014. The care plan lacked documentation of re-assessments for the AM and PM shifts on 12/02, the AM shift for 12/03 and the PM shift for 12/04, 12/05 and 12/06.

Patient #5 was admitted to the facility on 12/03/2014. A care plan was initiated on 12/04/2014. The care plan lacked documentation of re-assessments for the PM shift on 12/04, the AM shift for 12/05 and the PM shift for 12/06 and 12/07.

Patient #6 was admitted to the facility on 12/04/2014. A care plan was initiated on 12/06/2014 at 0130. The care plan lacked documentation of re-assessments for the AM shift on 12/06 and the PM shift on 12/07.

Patient #7 was admitted to the facility on 12/03/2014. A care plan was initiated on 12/03/2014. The care plan lacked documentation of re-assessments for the AM shift on 12/05 and the PM shift on 12/06.

Patient #8 was admitted to the facility on 11/27/2014. A care plan was initiated on 11/27/2014. The care plan lacked documentation of re-assessments for the AM shift on 11/30.

On 12/08/2014 during the above reviews with staff B (Chief Nursing Officer) when queried as to when nursing staff are supposed to initiate a plan of care, he stated, "Within 8 hours of admission." When queried as to how often nursing staff are supposed to review and update the patient's plan of care, he replied, "Every shift."

On 12/09/2014 between 0900 and 1400, a review of discharged records was conducted for patients #10-#20 and revealed the following:

Patient #10 was admitted to the facility on 11/25/2014 and discharged on 11/28/2014. The care plan was initiated on 11/26/2014. The care plan lacked documentation of re-assessments for the AM shift on 11/27.

Patient #11 was admitted to the facility on 11/17/2014 and discharged on 11/19/2014 . The care plans was initiated on 11/17/2014. The care plan lacked documentation of re-assessments for the AM shift on 11/18.

Patient #12 was admitted to the facility on 11/09/2014 and discharged on 11/24/2014 . The care plan was initiated on 11/10/2014. The care plan lacked documentation of re-assessments for the AM shift on 11/11, 11/12, 11/13, 11/14, 11/16-11/19, 11/22 and 11/23.

Patient #13 was admitted to the facility on 08/28/2014 and discharged on 09/03/2014 . The care plan was initiated on 08/28/2014. The care plan lacked documentation of re-assessments for the AM shift 08/28, PM shift on 08/29 and 08/31, AM shift on 09/01 and 09/02.

Patient #14 was admitted to the facility on 09/12/2014 and discharged on 09/16/2014 . The care plan was initiated on 09/12/2014. The care plan lacked documentation of re-assessments for the PM shift on 09/12, AM shift 09/13 and PM shift 09/14.

Patient #15 was admitted to the facility on 09/09/2014 and discharged on 09/12/2014 . The care plan was initiated on 09/09/2014. The care plan lacked documentation of re-assessments for the PM shift on 09/09, AM and PM shift on 09/10, PM shift on 09/11.

Patient #16 was admitted to the facility on 10/19/2014 and discharged on 10/23/2014 . The care plan was initiated on 10/19/2014. The care plan lacked documentation of re-assessments for the AM shift on 10/20, PM shift 10/21 and PM shift 10/22.

Patient #17 was admitted to the facility on 10/04/2014 and discharged on 10/12/2014 . The care plan was initiated on 10/04/2014. The care plan lacked documentation of re-assessments for the AM shift on 10/05, PM shift 10/07 and PM shift 10/08, AM shift 10/09 and 10/10.

Patient #18 was admitted to the facility on 09/25/2014 and discharged on 10/03/2014 . The care plan was initiated on 09/25/2014. The care plan lacked documentation of re-assessments for the PM shift on 09/25, AM and PM 09/26, PM shift 09/27, AM and PM shifts for 09/28, 09/29, AM shift 09/30, AM shift 10/01 and 10/02, PM shift on 10/03.

Patient #19 was admitted to the facility on 09/22/2014 and discharged on 10/09/2014 . The care plan was initiated on 09/22/2014. The care plan lacked documentation of re-assessments for the PM shift on 09/22, PM shift 09/23, AM and PM shift and 09/24 and 09/25, AM shift 09/27, PM shift 09/28, AM shift 09/29 and 09/30, PM shift 10/01, AM shift 10/02 and 10/04, PM shift 10/06, AM and PM shift 10/07.

Patient #20 was admitted to the facility on 06/24/2014 and discharged on 06/27/2014. The care plan was initiated on 06/24/2014. The care plan lacked documentation or re-assessments for AM shift 06/25/2014, AM and PM shift on 06/26.

On 12/09/2014, staff B was present during the record reviews and confirmed the missing care plan documentation as listed. When queried as to why staff are not documenting on the care plans, he stated, "I did not realize that they weren't."

On 12/09/2014 at 1300, a review of the facility's policy titled, "Patient Admission, Assessment/Re-assessment and Care Plan Development,
#106370-1-66, Issued: 01/02/14" was conducted. The policy revealed that "4. Re-Assessment:
a. Re-assessment will be performed on an ongoing basis and with every shift change.
b. The Care Plans will be reviewed and updated, at least once per shift.
d. Throughout the shift, all ongoing assessments, interventions and patient's response to care will be documented."