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Based on document reviews and interviews, nursing staff failed to ensure pain assessments and interventions were completed according to standards of practice, in two of eight patient records reviewed (Patients #2 and #3).

Findings include:

Facility policy:

The Assessment and Reassessment Nursing Documentation policy read, pain assessments are according to Lippincott Procedure.

Reference:

According to Lippincott, a numeric pain scale is a self-reported tool. The numbers range from 0 to 10, where 0 is no pain, 5 is moderate pain and 10 is the worst possible pain. Reassessment of pain at designated intervals according to the type of pain intervention used (for example, oral, IV (intravenous), or transdermal route is needed to evaluate progress toward pain management goals. Documentation should include initial assessment findings, any reassessment findings as indicated, an evaluation and changes since previous measurement, interventions performed, the patient's response to them and their progress toward pain management goals.

1. Nursing staff did not ensure patients' pain was reassessed according to standards of care.

a. Review of Patient #3's medical record revealed the patient was admitted to the main hospital on 8/8/18. According to the History and Physical, dated 8/9/18, Patient #3 had a ligation (the surgical procedure of closing off a blood vessel by means of a ligature or clip) of a lingual (relating to, near, or on the side toward the tongue) artery bleed.

On 8/9/18 at 8:30 p.m., Registered Nurse (RN) #1 documented in the nursing notes, the patient reported jaw/face pain with a pain level at a seven out of ten on a numeric pain scale, which was considered moderate intensity according to Lippincott. Review of the Medication Administration Record (MAR), showed RN #1 provided Patient #3 a narcotic pain reliever (Norco). At 10:58 p.m., Patient #3 was transferred to the Surgical/Trauma unit.

At 11:05 p.m., RN #2 assessed the patient's pain upon arrival. RN #2 documented Patient #3 had aching pain to her jaw/face. RN #2 documented the patient's pain level was reported as a five out of ten, with a documented pain goal "no pain". RN #2 documented she encouraged the patient to use the patient controlled device. The next documented pain assessment was not until almost 24 hours later, when RN #3 documented Patient #3's pain level as a five out of ten, which was the same intensity as the prior assessment.

On 8/11/18 at 1:50 a.m., p.m., RN #3 documented Patient #3's face/jaw was sore and the patient's pain level was reported as a six out of ten on a numeric scale. At 1:53 a.m., RN #3 administered an intravenous (IV) narcotic pain reliever (Fentanyl). The next pain assessment was not documented until two hours later. At 4:15 a.m., RN #3 documented the patient's pain level remained a six out of ten.

At 8:39 a.m., RN #4 documented the patient reported a pain score as seven out of ten. The RN documented the patient's jaw/face was sore. Review of the MAR revealed, RN #4 administered Tramadol at 8:45 a.m., then a Norco at 10:17 a.m. From 10:17 a.m. until 1:50 p.m., there was no evidence which showed RN #4 reassessed the patient's pain to see if the pain medications/interventions were effective.

At 1:50 p.m., RN #4 documented Patient #3 had reported a pain score as seven out of ten, which was the same intensity reported earlier at 8:39 a.m. Review of the MAR, showed RN #4 gave the patient Roxicodone (a narcotic pain reliever), Neurontin (nerve pain medication) and Flexeril (muscle relaxant). There was no evidence RN #4 reassessed the patient's response to the pain medication. Then, at 4:43 p.m., two hours and 45 minutes later, RN #4 documented she gave the patient ibuprofen (a nonsteroidal anti-inflammatory drug that can treat mild to severe pain). There was no evidence which described what was Patient #3's pain level at the time of administration.

b. On 6/26/19 an interview was conducted with RN #4. She explained her pain assessment process. RN #4 stated she assessed a patient's pain during the initial shift assessment. She said she assessed for pain intensity/level, location of pain and the type of pain. RN #4 stated, depending on what intervention was done for the patient's pain, she would determine when a pain reassessment would be conducted. RN #4 said if the medication had a fast onset, she would reassess the patient within 30 minutes and if the medication had a longer onset, then within one hour. RN #4 said she assessed the patient to see if the intervention worked and if it did not, then she would try something else.

RN #4 reviewed Patient #3's medical record, she confirmed there were "gaps" the day she provided the patient care on 8/11/18 and she should have reassessed the patient's pain level within one hour. RN #4 stated she did not chart the reassessment and did not remember why she had not done so.

c. Review of Patient #2's medical record revealed the patient was admitted to the main hospital's Surgical/Trauma unit, on 6/9/19, for abdominal pain. Review of the Pain Management Flowsheets revealed on 6/9/19 at 9:01 p.m., Patient #2's nurse (RN #8) documented the patient had pain in his abdomen which was aching and cramping. The patient's reported pain level was a six out of ten on the numeric scale. Review of the MAR showed, at 9:18 p.m., RN #8 administered the patient IV morphine (a narcotic to treat moderate to severe pain). The next pain assessment was not documented until over two hours later at 11:44 p.m. Patient #2's reported pain level was a six which was at the same intensity as the 9:01 p.m. assessment.

d. On 6/26/19 at 3:37 p.m., an interview was conducted with the Manager of the Surgical/Trauma unit (Manager #5) and the Orthopedic unit manager (Manager #10). Manager #5 stated pain assessments were done with any intervention. Manager #5 stated nursing staff were to document within one hour of the intervention, the patient's pain level, whether or not the patient felt the intervention was effective, the time of the intervention and the patient's pain level. She stated an hour reassessment was the standard protocol.

Manager #5 reviewed Patient #3's pain assessments. She stated on 8/9/18, nursing staff should have re-assessed the patient's pain within one hour of the Norco administration. She then reviewed Patient #3's pain management assessments for the night shift on 8/10/18 through 8/11/18 a.m. Manager #5 stated IV Fentanyl was a pain medication with a short half-life (the time for the drug to eliminate from the body). She said the patient's pain should have been assessed within one hour to see if the IV Fentanyl was effective. Manager #5 reviewed the pain management assessments conducted on the day shift for 8/11/18. She confirmed there was no documentation which showed the RN reassessed Patient #3's pain. Additionally, Manager #5 said the patient had other medications ordered which could have been administered to help manage the patient's pain.

e. On 6/27/19 at 10:35 a.m., the facility provided the most recent audits for the Surgical/Trauma unit and the Surgical unit. The Pain Documentation Audits, dated May 2019, showed the Surgical/Trauma unit was at 43% compliance for post pain intervention assessments and the Surgical unit at the offsite hospital, was at 60% compliance for post pain intervention assessments.