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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 NURSING SERVICES was out of compliance.

A-0395 §482.23 (b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. Based on interviews and document review, the facility failed to provide nursing services in accordance with facility protocol and policy. Specifically, the facility failed to provide pain interventions and reassess the effectiveness of pain management interventions implemented for patients in pain in three of four medical records reviewed.

Based on interviews and document review, the facility failed to provide nursing services in accordance with facility protocol and policy. Specifically, the facility failed to provide pain interventions and reassess the effectiveness of pain management interventions implemented for patients in pain in three of four medical records reviewed. (Patients #1, #3, and #4)

Findings include:

Facility policy:

The Pain Management policy read, documentation of pain assessment is completed on admission, during and after any known pain-producing event, with each new report of pain, and at least once a shift. Pain reassessment timeframe and/or interval is based on patient assessment and knowledge of the onset and peak effect of the intervention provided. Documentation of reassessment will be within one hour of as needed (PRN) pain medication. Reassessment of pain includes the pain level using an appropriate pain scale.

1. The facility failed to ensure staff provided pain interventions and reassessed after pain management interventions according to facility protocol and policy.

A. A review of medical records revealed gaps in the pain management policy being followed for patient's pain management.

i. On 8/2/24, Patient #1 arrived at the emergency department (ED) with leg pain and was admitted for sepsis (a condition caused by severe infection). Patient #1 had a history of a left below the knee amputation (BKA) and peripheral neuropathy (a condition where the nerves become damaged and cause pain, usually in the hands and feet). Patient #1's provider ordered Tylenol, oxycodone, Dilaudid, and Robaxin for their pain management. On 8/2/24 at 11:57 a.m., Patient #1 received oxycodone for leg pain at a level 8 out of ten pain scale (8/10). There was no reassessment completed to determine if Patient #1 had relief. At 7:33 p.m., Patient #1 stated their leg pain was 10/10, however, Patient #1 did not receive pain medications again until 8/3/24 at 6:39 a.m. Patient #1 received oxycodone at that time for leg pain 7/10. There was no reassessment completed to determine if Patient #1 had relief. On 8/3/24 at 8:45 a.m., Patient #1 stated they had generalized pain 8/10, however, Patient #1 did not receive pain medications (Robaxin) again until 11:33 a.m. for pain 8/10. Further examples of no pain reassessment to determine the effectiveness of the pain medication were identified on 8/4/24, 8/5/24, 8/6/24, and 8/7/24.

ii. On 9/8/24, Patient #2 arrived at the ED with symptoms of lethargy (feeling exhausted and without mental alertness) and chills. Patient #2 was admitted for sepsis of a right BKA. Patient #2 fell on 9/18/24 and fractured their left leg and required pain medication. Patient #2's provider ordered oxycodone, Dilaudid, Tylenol, and Robaxin for pain management. On 9/18/24, Patient #2 received Robaxin at 3:21 p.m. for leg pain 8/10 but staff did not reassess to determine the effectiveness of the pain medication. On 9/19/24, Patient #2 received Tylenol for left leg pain 6/10 at 10:39 a.m. but staff did not reassess to determine the effectiveness of the pain medication. Further examples of no reassessment which determined the effectiveness of the pain medication were identified on 9/18/24, 9/19/24, 9/22/24, and 9/26/24.

Additionally, on 9/23/24 at 9:03 p.m., Patient #2 had leg pain 5/10 but did not receive pain medication until 9/24/24 at 9:15 a.m. Similarly, on 9/24/24 at 9:27 p.m., Patient #2 had leg pain 5/10 with no pain management interventions performed.

iii. On 9/20/24, Patient #4 arrived at the ED with chills and concerns of a right BKA infection. Patient #4 was admitted to treat the confirmed infection in the right BKA. Patient #4 had a history of chronic back pain and their provider ordered Tylenol and Tramadol for pain management. On 9/21/24 at 8:30 a.m., Patient #4 received Tylenol for 6/10 back pain, but staff did not reassess to determine the effectiveness of the pain medication. On 9/22/24 at 8:27 a.m., Patient #4 had 8/10 left sided back pain. Record review revealed Patient #4 had medication administered, however, no documentation of pain medication administration was found during this time. Patient #4 did not have a reassessment until 11:43 a.m., when the patient reported a pain score of 7/10. On 9/22/24 at 9:57 p.m., Patient #4 had 5/10 left sided back pain, but had no pain management intervention until 12:09 a.m. when they received Tylenol. Further examples of no pain reassessment to determine the effectiveness of the pain medication were identified on 9/20/24, 9/23/24, 9/25/24, and 9/26/24.

The record reviews were in contrast to the Pain Management policy which read, staff based pain reassessment on patient assessment and the peak effect of the intervention provided. Reassessments included documentation within one hour of the PRN pain medication.

B. Interviews

i. On 11/20/24 at 10:36 a.m., an interview was conducted with registered nurse (RN) #1. RN #1 stated they assessed patients for pain every shift and each time they took vital signs. RN #1 stated they assessed patients to ensure patients did not have any new pain which required provider notification. RN #1 stated they completed a reassessment within an hour of the pain management intervention to determine if the pain medication worked to treat the patient's pain. If the pain medication did not work, RN #1 stated they called the provider to determine other possible interventions for the patient. RN #1 stated pain management and reassessment was important to ensure poor outcomes did not occur, such as pain crisis, immobility which resulted in skin breakdown, pneumonia, blood clots, or longer hospitalizations. RN #1 stated reassessment ensured good pain management for patient mobility and decreased adverse event outcomes.

ii. On 11/20/24 at 11:52 a.m., an interview was conducted with clinical nurse manager (Manger) #2. Manager #2 stated the expectations for pain management and reassessment included frequent interventions, reassessments, and provider notification if a pain medication did not effectively treat the patient's pain. Manager #2 stated staff completed reassessments within the hour of the intervention. Manager #2 stated the electronic medical record automatically reminded staff when the reassessment was due so staff should not have missed the reassessment. Manager #2 stated they trained staff upon hire as well as during inpatient unit education when their audits showed an increase in outliers in reassessment documentation. Manager #2 stated it was necessary for RNs to reassess a patient's pain because it ensured pain was managed and patients did not experience complications related to poor pain control.

iii. On 11/20/24 at 9:47 an interview was conducted with medical provider (Provider) #3. Provider #3 stated a pain level of 8/10 was significant and needed treatment. Provider #2 stated RNs made providers aware of patient pain management issues and providers wrote pain medication orders which included patient safety from adverse events caused by pain medication. Provider #3 stated it was important to keep patients comfortable without creating an oversedation situation from too much pain medication that would make the situation worse.

The interviews were in contrast to the medical record reviews which revealed patients experienced pain but did not receive pain management interventions and reassessments which determined the effectiveness of the interventions.