HospitalInspections.org

Based on document review and interview, the registered nurse failed to ensure a patient's weight was obtained upon admission, failed to ensure a pain screening was completed every eight (8) hours, failed to perform a post pain intervention and reassess/document pain/intervention for one (1) of ten (10) patients. (Patient # 10)

Findings include:

1. Review of the facility policy titled, "Patient Admission, Assessment, Reassessment and Documentation Guidelines, and Vital Signs Procedures", policy number NSI-ACT_30, indicated the nurse shall obtain and enter the weight information into the Admission Navigator. This policy was last revised in 02/2021.

2. Review of the facility policy titled, "Pain Management", policy number NSI-PAIN_01, indicated all patients will be screened for pain during the physical assessment every eight (8) hours, if pain is present assess and document, a pharmacological and/or non-pharmacological intervention should be performed and then the patient should be reassessed/documented. This policy was last revised in 02/2021.

3. Review of patient # 10's medical record (MR) indicated the following:
a. The patient was admitted to H # 2's (Acute Care Hospital) on 01/07/2022.
b. The patient's weight was documented as 200 pounds (lbs) on 01/08/2022 and 01/09/2022 not by being weighed on a scale but from the patient's self report of their weight. The patient's weight was documented as 179 lbs on 01/23/2022.
c. The MR lacked pain screenings every eight (8) hours per policy on the following dates: 01/16/2022, 01/17/2022, 01/20/2022, 01/22/2022, 01/25/2022, 01/27/2022, 01/29/2022, 01/30/2022, 02/08/2022, 02/11/2022, 02/12/2022, 02/13/2022, 02/14/2022, 02/15/2022, 02/16/2022, 02/17/2022, 02/18/2022, 02/19/2022, 02/20/2022 and 02/21/2022.
d. On 02/09/2022 at 8:00 am the patient complained of back pain which was a five (5) out of ten (10). The patient was repositioned. The MR lacked documentation a reassessment was completed at 9:00 am.
e. On 02/09/2022 at 10:00 am the patient complained of generalized pain which was a five (5) out of ten (10). The patient was given medication. The MR lacked reassessed pain scale documentation at 11:00 am.
f. On 02/09/2022 at 4:00 pm the patient complained of abdominal pain which was a seven (7) out of ten (10). The MR lacked documentation a reassessment was completed at 5:00 pm.
g. On 02/15/2022 at 10:00 am the patient complained of buttock pain which was a eight (8) out of ten (10). At 10:27 am the patient complained of abdominal pain. The MR lacked documentation of any interventions were completed.

4. In interview dated 04/20/2022 at approximately 2:50 pm with A # 3 (Assistant Vice President-AVP), confirmed any intervention should be reassessed.

5. In interview dated 04/20/2022 at approximately 3:10 pm with A # 1 (AVP), confirmed patients should be screened for pain every eight (8) hours.

6. In interview dated 04/21/2022 at approximately 10:15 am with A # 4 (Director of Critical Care), confirmed the nurse failed to perform an intervention and failed to reassess the patient after an intervention.