HospitalInspections.org

Based on interview and record review, the facility failed to ensure that an RN evaluated the care of each patient. Nursing staff failed to perform a pain reassessment after administering intravenous (IV) pain medication to 2 of 2 sampled patients [ Patient # 5, 6].

Findings included:

Review of facility policy titled " Pain Assessment and Management," dated 10/03/2022, showed : Purpose: patients have the right to have their pain assessed and appropriately managed.... H, Interventions: 4. Monitor, reassess, and document the effectiveness of pharmacological and non-pharmacological interventions in Pain Assessment Electronic Medication Administration Record (eMar) ...at the following intervals: b. IV medications: ADULTS: 30-60 minutes ( 0.5- 1 hour) after administration.

Record review of 2 current patient medical records on 4/24/2024 on 7 M Tower with Staff -F, RN, showed the following:

Patient ID # 5 was administered a scheduled dose of IV Dilaudid 1 milligram (mg) for pain management on 4/22/2024 at 1858. Patient # 5's pain was assessed as 7 / 10 prior to being given the drug. Her pain was not reassessed after the administration of the IV Dilaudid.

Patient ID # 6 was administered a PRN ( as needed ) dose of IV Dilaudid 2 mg for pain management on 4/18/2024 at 1205. Patient # 6's pain was assessed as 7 / 10 prior to being given the drug. Her pain was not reassessed after the administration of the IV Dilaudid.

During an interview on 4/24//2024 at 1:15 PM with Staff-F, RN, she stated that patients should be reassessed for effectiveness of the IV pain medication within 30 to 60 minutes after it was given. Staff-F said this was true for both scheduled and PRN does of IV pain medication.