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Based on interview and record review, the facility failed to followed policies and procedures for assessing (evaluate) and reassessing (repeating evaluation) one of thirty sampled patients (Patient 1) for pain.

This deficient practice has the potential for Patient 1 ' s need for comfort not being met.

Findings:

A review of Patient 1 ' s face sheet (a document summarizing a patient ' s key information, including demographics, medical history, allergies, medications, and other vital details), dated 6/19/2024, indicated Patient 1 was admitted with diagnosis of colitis (inflammation in the colon, often infectious).

On 6/10/2025, at 11:22 a.m., during concurrent interview with Registered Nurse (RN) 6 and Nurse Educator (RN) 7 and record review of Patient 1 ' s history and physical (H&P – a comprehensive assessment conducted by a physician to gather information about a patient ' s health status), dated 6/19/2024, RN 6 stated the following:

Patient has abdominal pain and fussiness, which began two days ago, with a fever of 101.4 degrees, Fahrenheit (a scale of measuring temperature) which worsened to 102 degrees Fahrenheit, the day before, with increasing pain and fussiness.

Patient returned to the emergency department (ED) on 6/19/2024, after seeing the pediatrician, who advised the parents to take patient back to the ED.

Physical exam – patient ' s abdomen was soft, non-tender with mild distention.

Orders included clear liquid diet, hold off on antibiotics, and Tylenol or Motrin for pain and/or fever.

Consulted for surgery – no surgery at this time.

Gastrointestinal (GI-passageway from the mouth to the opening end of the body) consult for tomorrow in the morning.

On 6/11/2025, at 9:40 a.m., during concurrent interview with RN 8 and record review of Patient 1 ' s Nursing Notes, dated 6/20/2024, RN 8 stated patient had moderate pain with a pain score of 5 out of 10 (screening tool used to assess pain, zero-no pain and 10 being the worst pain ever) at 2:00 p.m.

During concurrent review of Patient 1 ' s medication administration record (MAR – a document used to track and record all medications administered (given) to a patient), dated 6/20/2024, RN 8 stated patient was given Tylenol (pain medication) 180 milligrams (mg-unit of mass in the metric system) by vein (IV-within the vein)) at 4:00 p.m.

Concurrently, during record review of Patient 1 ' s physician orders for pain, dated 6/20/2024, RN 8 stated Patient 1 had two physician orders for pain medication:

Tylenol 180 mg IV every 6 hours for mild pain for a pain score of 1-3out of 10 total, and

Toradol (medication use for pain relief)7.05 milligrams (mg) by vein (IV) every six hour for moderate pain (pain score 4-6 out of 10 total)

Concurrently, RN 8 stated Patient 1 should have been administered Toradol for moderate pain because patient had moderate pain. Instead, patient was given Tylenol, which was ordered for mild pain.

A review of facility ' s Pain Assessment and Management policy, dated 12/2/2024, indicated the following:

The physician (MD) and registered nurse (RN) are responsible for the assessment and reassessment of pain the effectiveness of interventions.

The MD is responsible for ordering pharmacologic agents (pain medication) and administering and monitoring the pain medications.

Licensed nursing personnel are responsible for the administration and monitoring of pain medication.

The patient ' s right to pain management across the continuum (on-going) of care is respected and supported.

The identification (information regarding a person identity) of patients experiencing pain or discomfort and its management are integral to the mission of patient care.

The effective management of pain is contingent upon appropriate initial and ongoing pain assessment.

Pain assessment will be assessed for the presence or absence of pain on admission and in accordance with unit-based minimal monitoring parameters per policy, assessment of the patient.

A review of facility ' s Assessment of Patient, dated 12/13/2023, indicated the following:

RN ' s are responsible for the assessment and prioritization of a patient ' s need at the time of initial assessment and throughout the patient ' s stay.

Initial patient assessment is completed within 24 hours of admission.

The RN caring for the patient at the 20th hour post-admission, has the responsibility to ensure the completion of the interdisciplinary patient assessment, which is documented in the electronic health record.

RN ' s perform reassessments based on individualized and prioritized needs to evaluate response to treatment and therapies and to determine the effectiveness of the interventions.

Initial vital signs (VS-measurements of the body ' s most major function)) upon arrival at the bedside and every 15 minutes, thereafter, until arrival to facility.

A final set of vital signs (VS) is done upon handoff to receiving unit.

Complete VS included the presence of pain or discomfort, height and weight, and a head-to-toe assessment, within one (1) hour of admission, or sooner, according to the specific needs of the patient.

Licensed staff are to directly observe patients every two hours.

The presence or absence of pain or discomfort is assessed every four (4) hours in general pediatric unit and every two (2) hours in pediatric intensive care unit (PICU – a specialized unit within a hospital that provides the highest level of care for critically ill or injured children) and is reassessed based on pain score within 60 minutes of medication administration.