HospitalInspections.org

Based on medical record review, interview and policy review, the hospital failed to ensure a registered nurse evaluated the nursing care for one of 11 patients reviewed (Patient #1). This could affect all patients receiving services from this facility. The patient census was 30.

Findings include:

Review of the policy and procedure titled, Pain Management Plan, H-PC 03-11 revealed on page 2 of 8 that the registered nurse (RN) assessment (in addition to the pain scale rating), will be documented in the patient medical record and includes the following elements, pain location (including radiation), pain character, and pain duration. On page 3 of 8 it stated reassessment of pain is conducted through evaluation and documentation of response to pain interventions and recommended timeframes for reassessment of effectiveness of pain relief may include one hour reassessment for oral medication and non-pharmacological interventions.

Review of the medical record for Patient #1 revealed pain medication orders included Acetaminophen 650 milligrams (mg) every four hours as needed, start on 10/22/19 and end 11/11/19, Acetaminophen 650 mg every eight hours routine start on 11/03/19 and end on 11/11/19.

Acetaminophen 650 mg was given on 11/10/19 at 7:08 PM. There was no documentation as to the location of the pain, pain character, or pain duration.

Tramadol 50 mg was ordered on 11/05/19 at 8:54 PM every eight hours as needed for severe pain (rated 7 to 10 on the pain scale). The first dose was given on 11/06/19 at 7:46 AM for back pain that was rated a 9 out of 10. There was no documentation of a reassessment for effectiveness of pain relief.

This finding was confirmed in an interview on 08/19/2020 with the administrative staff prior to the exit conference.