HospitalInspections.org

Based on review of medical records, facility policy and procedures, and staff interviews, it was determined that the facility failed to ensure that one patient (P) P#1 of four sampled patients (P#1, P#2, P#3, and P#4), received pain medication in a timely manner per physician's orders. Specifically, nursing staff were unable to view electronic physician orders for P#1 due to an IT error which resulted in a delay in medication administration.


Findings include:


A review of the facility's Complaint and Grievance log revealed that P#1 submitted a complaint on 9/18/25 related to courtesy, respect, and promptness to needs and requests. A second complaint was submitted on 9/18/25 related to coordination of care.


A review of medical records for P#1 revealed that she was admitted to the facility on 9/17/25 for a cervical revision of C6-C7 ACDF & C5-C6 revision ACDF (a surgical procedure that involves joining two or more vertebrae in the neck to stabilize the cervical spine and alleviate pain).


The nurse practitioner (NP) entered orders on 9/17/25 at 7:19 p.m. for P#1 to receive 1000 mg of acetaminophen (analgesic) intravenously (medicine administered through a catheter directly into a vein) (IV) every six hours for 24 hours.

A review of P#1's 'Medication Administration Record' (MAR) revealed that P#1 received the first dose of acetaminophen 1000 mg IV at 1:22 a.m. on 9/18/25.


An "Occupational Therapy Form" revealed that P#1 participated in therapy on 9/18/25 at 9:56 a.m. P#1's head pain score was a level 3 (pain scale measures the level of pain per the patient with 0 being 'no pain' and 10 being the worst pain imaginable). The Occupational Therapist (OT) reassessed P#1's pain at the end of the session and notified the nurse that the pain score was a level 3 and that P#1 requested pain medication.


A review of the facility's policy titled "Pain Management -System," number 11342, last revised 10/4/23 revealed that the purpose of this policy was to outline the facility's guidelines for the safe and effective management of pain, documentation of pain, staff education, and performance improvement efforts related to pain.
The facility was committed to ensuring that patients received optimal comfort & pain control through a proactive pain management plan that was developed through patient, family, significant other and healthcare team member collaboration. Appropriate pain assessment, effective pain management, utilization of non-pharmacologic interventions and medications, and safe opioid prescribing practices were a priority. The facility's approach to pain management was based on the following principles:
1.The experience of pain was subjective and may have been affected by age, gender, and/or culture.
2. Clinicians accepted and respected a patient and family's report of pain.
3. Regular pain assessments were essential elements in successful pain management.
4. A pain management plan was individualized.
5. Timely interventions were critical to managing pain.
6. Patients were allowed choice and input in their pain management plan.
7. The treatment of pain should have been effective while minimizing any risks associated with the pain treatment plan. Procedures included Initial pain assessment:
1. Staff should have screened patients for the presence of pain on admission:
To any inpatient setting
2. The pain interventions should have evaluated and updated to reach an effective level determined by
the patient when possible and as appropriate to the patient's clinical condition.

Patient Pain Relief Effectiveness
1. Assisted patients to identify an acceptable level of pain that should have allowed them to perform activities related to recovery.
2. Evaluated relief in terms of the patient's acceptable level of pain whenever assessing pain.
3. Implemented pain interventions when patients' pain intensity exceeded their acceptable level.
4. Patients should have changed the level of pain that was acceptable for them at any time.
Pain Assessment/Reassessment Elements
Pain assessment/reassessment elements included:
1. Pain intensity: measured using an appropriate pain scale based on the patient's age, clinical condition and ability to understand. Use a pain scale that supported patient condition and considered patient's ability to understand and communicate.
2. Description of pain
3. Onset / duration
4. Aggravating factors
5. Location of pain and assessment of site
6. Treatment history (past and current), which included
-Effectiveness of previous relief measures
-Effect on activities of daily living (ADL's)


A review of the facility's policy titled "Medication Administration," number 36027, last reviewed 11/5/24 revealed the purpose of the policy:
1. Provided guidelines for safe and timely administration of medications to patients.
2. Provided guidelines for documentation of medications.
3. Provided guidelines for consistent scheduling of medications and define medication categories in which timing was critical.


During an interview with Registered Nurse (RN) BB in the boardroom at 1:25 p.m., on 10/01/25, RN BB stated that he worked at the facility for four years as an RN. RN BB's duties included working in the Post Anesthetic Care Unit (PACU) assessing patients for pain and making sure that their airway was protected. RN BB reported that he assessed patients for pain by asking them their pain level on the pain scale if they were able to talk. For patients that were unable to communicate, RN BB assessed patients by observing grimacing, and elevated heart rate and blood pressure.

RN BB explained that post operative medications were entered into the patient's electronic chart by the surgeon and that the orders followed the patient to the hospital floor when transferred from the recovery room.

RN BB recalled that P#1's surgery was postponed the previous day, 9/16/25, due to a sterile tray contamination. He further recalled that P#1 was not happy that her surgery was postponed to 9/17/25.

RN BB acknowledged that if he had a patient whose medication was not in the patient's chart, he would call the anesthesiologist and ask them to put it in. If that did not work, RN BB reported that he would then contact the charge nurse to report it. RN BB further acknowledged that he would also reach out to registration to see if there were two accounts and ask them to merge them.


During a telephone interview with Nurse Practitioner (NP) EE on 10/1/25 at 1:38 p.m., NP EE reported she prescribed P#1's pain medication which included: intravenous Tylenol, Percocet, and Dilaudid (pain medications) to be administered PRN (as needed) every 6 hours for 24 hours. NP EE further reported that she received several phone calls from the unit staff reporting that they could not see the orders for P#1. NP EE reported that she put the orders in several times and did not know why the unit staff could not see the orders. NP EE requested that the charge nurse get in touch with (Information Technology) IT or bed control to assist with the problem.
NP EE did not understand how P#1 was able to get her post operation orders for x-ray but not her orders for medication. NP EE reported that she thought the problem was solved once she stopped receiving phone calls. NP EE recalls the nurse saying that she called IT but they were not available at night. NP EE acknowledged that it was "unbelievable," that P#1 did not receive her medication as prescribed.
NP EE reported that there was a system called Omni Cell that could have been utilized. It was a global list where all orders could be accessed.


During a telephone interview with Registered Nurse (RN) AA 10/1/25 at 4:44 p.m., she reported that she worked night shifts and that her duties included direct patient care. RN AA recalled that P#1 came up to her unit on the eighth floor right after shift change. RN AA recalled that P#1 did not complain about having pain. RN AA further recalled that taking P#1 to the bathroom two to three times during the night without complaining about pain. RN AA explained that she was able to access P#1's pain medication, especially intravenous Tylenol with some difficulties but it did not affect P#1's care. RN AA further explained that P#1 had two financial information numbers (FIN's). RN AA explained that she could access more pain medication if it was needed. RN AA recalled in that in the morning between 5:30 a.m. and 6:30 a.m., P#1 expressed her wishes to go home to the NP EE.