HospitalInspections.org

Based on document review and interview, nursing services failed to complete a pain assessment prior to administration of pain medication for 1 of 10 patient (patient 6) medical records reviewed; and failed to complete a pain reassessment to ensure effective pain management for 1 out of 10 patient (patient 6) medical records reviewed.

Findings include:

1. Facility policy titled, Pain Assessment, Reassessment, Management and Care Plan, PolicyStat ID 12197199, last approved 08/2022, indicated ongoing pain assessment and effectiveness of interventions completed by all disciplines participating in the care of the patient. If applicable, efficacy of intervention shall be documented prior to the end of the shift.

2. Review of Patient 6's medical record lacked documentation of a pain assessment on 04/06/2024 and 04/07/2024 and the efficacy of intervention, pain reassessment, after pain medication administration on 04/04/2024, 04/06/2024, and 04/07/2024.

3. Interview with A1 (Chief Executive Officer) and A2 (Director of Nursing) on 05/01/2024 at approximately 5:45 p.m. confirmed that patient 6 MR lacked documentation of pain assessment prior to pain medication on 04/06/2024 and 04/07/2024 and reassessment after pain medication administration on 04/02/2024, 04/04/2024, 04/06/2024 and 04/07/2024.