HospitalInspections.org

Based on review of facility policy and procedure, staff interview and review of two out of three medical records of patients receiving pain medications (Patient (P)3 and P4), it was determined that the facility failed to ensure that pain is reassessed and documented with each administration of pain medication.

Findings include:

Reference #1: Facility Policy titled, "Pain Management Procedure" (effective 6/15/22), states, " ...Purpose ...To ensure the right of every patient to have his/her pain assessed and effectively managed throughout the continuum of care. ...RN. Performs all subsequent pain assessment and reassessments. Assessment/reassessment includes pain intensity using an appropriate pain scale, location, onset, and other factors when indicated. ... RN. Pain reassessment is completed within 1 hour of an intervention."

On 3/27/23 at 12:35 PM, during an interview with Staff (S) 8, he/she explained that when pain medications are administered, the pain should be reassessed and documented within one hour. S8 demonstrated how in the Medication Administration Record (MAR), a red box labeled "Medication Administration Follow Up" appears after a pain medication is given to prompt the nurse to reassess the patients pain. Once this red box is checked it opens the pain assessment flow sheet so the pain reassessment can be documented.

On 3/27/23 at 12:38 PM, during review of P3's Medication Administration Record (MAR), the following was revealed: On 3/26/23 at 3:40 PM, P3's pain was assessed as a 7 out of 10, and P3 received 10 milligrams (mg) of Oxycodone orally (PO). The medical record lacked evidence that P3's pain was reassessed within one hour. On 3/26/23 at 4:48 PM, P3's pain was assessed as 9 out of 10 and P3 received 0.5 mg of Dilaudid intravenously (IV). The medical record lacked evidence that P3's pain was reassessed within one hour. On 3/27/23 at 6:36 AM, P3's pain was assessed as a 7 out of 10 and P3 received 0.5 mg of Dilaudid IV. The medical record lacked evidence that P3's pain was reassessed within one hour. On 3/27/23 at 9:47 AM, P3's pain was assessed as a 9 out of 10 and P3 received 0.5 mg of Dilaudid IV. The medical record lacked evidence that P3's pain was reassessed within one hour.

On 3/27/23 at 12:40 PM, during review of P4's Medication Administration Record (MAR), the following was revealed: On 3/27/23 at 5:54 AM, P4's pain was assessed as a 8 out of 10 and P4 received 1 mg of Dilaudid IV. The medical record lacked evidence that P4's pain was reassessed within one hour.