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Based on interview and record review, the hospital failed to ensure the nursing care and services were provided for three of six sampled patients (Patients 1, 2 and 3) when the nursing staff did not ensure the pain management for Patients 1, 2, and 3 as per the hospital's P&P. This failure created the increased risk of poor health outcomes to the patients in the hospital.

Findings:

Review of the hospital's P&P titled Pain Assessment/Management and Safe Opiate Prescribing dated June 2024 showed the following:

* Pain management and safe opiate prescribing is a priority.

* The patients have the right to appropriate assessment and management of pain. The procedure includes the initial assessment of any pain that a patient may be experiencing is documented as part of nursing assessments. A 1-10 numeric Pain Intensity Scale is used. The assessment includes the location and description of the pain the patient is experiencing.

* Reassessment of a patient's pain is done by the nursing staff every shift or as appropriate after medication administration and documented on the nursing progress note. Any significant change will be reported to the Internist.

1. Review of Patient 1's closed medical record was initiated on 9/13/24 at 0730 hours.

Patient 1's closed medical record showed the patient was admitted to the hospital on 8/24/24, and discharged on 8/29/24.

Review of the RN Progress Note dated 8/24/24 at 1807 hours, showed the RN documented a problem of physical assault. The RN Progress Note showed at approximately 1630 hours, Patient 1 was involved in a physical altercation with other patients. Patient 1 suffered minor scratches and reported pain to her head.

However, review of Patient 1's closed medical record failed to show documented evidence the RN had performed a complete pain assessment as per the hospital's P&P.

On 9/17/23 at 1008 hours, an interview and concurrent review of Patient 1's closed medical record was conducted with the CNO and Director of Quality. When asked if the staff needed to assess Patient 1's reported head pain, the CNO stated if someone reported pain, it would be assessed, but the CNO could not speak for the nurses. When asked if the pain assessment was documented, the Director of Quality stated no. The CNO acknowledged the findings.

On 9/17/24 at 1038 hours, an interview and concurrent review of Patient 1's closed medical record was conducted with RN 1, the CNO, and Director of Quality. RN 1 stated there was a minor scratch on Patient 1's face and the patient reported pain on the head. RN 1 stated the patient complained of pain all over her body to the paramedic staff. RN 1 was asked if the pain assessment was documented. RN 1 stated it was reported to the doctor but not documented. RN 1 also confirmed there was an order for Tylenol (pain medication), but the CNO found it was not given. RN 1 stated probably, it was offered, but the patient declined.

On 9/17/24 at 1635 hours, the CNO, Director of Quality, and CEO were informed and acknowledged the findings.


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2. Review of Patient 2's medical record showed Patient 2 was admitted to hospital on 7/31/24.

Review of the MAR dated 8/11/24, showed Patient 2 had a physician's order for acetaminophen (or Tylenol) oral tablet 325 mg, one tablet every four hours as needed.

Review of the flowsheet dated 8/11/24 at 0611 hours, showed Patient 2 was assessed for a pain scale of 8 (on a pain scale of 0 to 10 with 0 = no pain and 10 = most pain).

Review of MAR dated 8/11/24 at 0611 hours, showed one acetaminophen 325 mg tablet was administered to Patient 2.

No documented pain reassessment for effectiveness after Patient 2 received a 325 mg acetaminophen tablet was found in Patient 2's medical record.

Review of the MAR dated 8/11/24 at 1416 hours, showed one acetaminophen 325 mg tablet was administered to Patient 2.

Review of the flowsheet dated 8/11/24 at 1416 hours, no documented assessment or reassessment for pain even though a pain medication was given to Patient 2.

Review of the flowsheet dated 8/11/24 at 2031 hours, showed Patient 2 was assessed for a pain level of 8.

Review of the Acute Nursing Progress Note dated 8/11/24 at 2031 hours, showed Patient 2 was assessed for a pain level of 8.

Review of the MAR dated 8/11/24 at 2031 hours, showed one acetaminophen 325 mg tablet was administered to Patient 2.

No documented pain reassessment for effectiveness after Patient 2 received a 325 mg acetaminophen tablet was found in Patient 2's medical chart.

Review of the Acute Nursing Progress Note dated 8/14/24 at 2030 hours, showed Patient 2 was assessed for a pain level of 0.

Review of MAR dated 8/14/24 at 2030 hours, showed one acetaminophen 325 mg tablet was administered to Patient 2 for the pain level of 0.

No documented pain reassessment for effectiveness after Patient 2 received a 325 mg acetaminophen tablet was found in Patient 2's medical chart.

On 9/17/24 at 1320 hours, a concurrent interview and review of Patient 2's medical record was conducted with the CNO. The CNO reviewed the P&P and verified it applied to Patient 2. The CNO stated the expectation was for the nursing staff to assess the patient for pain using the 1 to 10 pain scale as shown in the policy. The purpose was to determine if the patient had pain, to treat the pain, and then reassess to see how effective the treatment was. The pain assessment was to be documented in the patient's medical records in the flowsheet, nursing progress note, or the memo field. The CNO stated the next step in the process was to provide the patient with pain relief in the form of the prescribed medication. The CNO also stated the nurse was expected to return and reassess the patient's pain after taking the treatment (medication) to assess the effectiveness of medication and document the reassessment in the patient's medical record. The CNO reviewed Patient 2's medical record and verified the above documented notes, memos, and flowsheets. The CNO reviewed Patient 2's medical record including the MAR with the times pain medications was given, nursing progress notes, and flow sheets on 8/11 and 8/14/24. The CNO verified on 8/11/24, Patient 2 had an order for acetaminophen. The CNO reviewed and verified Patient 2 was given the pain medication on 8/11/24 at 0611 hours for a documented a pain level of 8, but there was no documented reassessment for effectiveness of treatment. The CNO reviewed and verified Patient 2 was given the pain medication on 8/11/24 at 1416 hours, but no documented pain assessment and reassessment for the effectiveness of the administered pain medication were found in the patient's medical record. The CNO reviewed and verified Patient 2 was given the pain medication on 8/11/24 at 2031 hours, for a documented pain level of 8, but there was no documented reassessment for effectiveness of treatment.

3. Review of the patient's medical record showed Patient 3 was admitted to hospital on 9/4/24.

a. Review of the MAR showed Patient 3 had a physician's order for acetaminophen 325 mg tablet, two oral tablets every four hours as needed.

Review of the MAR dated 9/6/24 at 0648 hours, showed two acetaminophen 325 mg tablets were administered to Patient 3.

On 9/6/24 at 0648 hours, no pain assessment or reassessment was documented in Patient 3's medical chart.

Review of the MAR dated 9/6/24 at 1251 hours, showed two acetaminophen 325 mg tablets were administered to Patient 3.

On 9/6/24 at 1251 hours, no pain assessment or reassessment was documented in Patient 3's medical chart.

Review of the MAR dated 9/7/24 at 1036 hours, showed two acetaminophen 325 mg tablets were administered to Patient 3.

Review of the flowsheet dated 9/7/24 at 1041 hours, showed Patient 3 was assessed for a pain level of 4.

No documented pain reassessment for effectiveness after Patient 3 received two acetaminophen 325 mg tablets was found in Patient 3's medical record.

Review of the MAR dated 9/10/24 at 1059 hours, showed two acetaminophen 325 mg tablets were administered to Patient 3.

Review of the flowsheet dated 9/10/24 at 1100 hours, showed Patient 3 was assessed for a pain level of 4.

No documented pain reassessment for effectiveness after Patient 3 received two acetaminophen 325 mg tablets was found in Patient 3's medical record.

b. Review of the MAR dated 9/10/24, showed Patient 3 had an order for ibuprofen (pain medication) oral tablet 400 mg, one tablet every six hours as needed.
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Review of the MAR dated 9/10/24 at 0139 hours, showed one ibuprofen oral 400 mg tablet was administered to Patient 3.

Review of the flowsheet dated 9/10/24 at 0140 hours, showed Patient 3 was assessed for a pain level of 8.

No documented pain reassessment for effectiveness after Patient 3 received one ibuprofen oral 400 mg tablet was found in Patient 3's medical record.

Review of the MAR dated 9/10/24 at 0822 hours, showed one ibuprofen oral 400 mg tablet was administered to Patient 3.

Review of the Acute Progress Note dated 9/10/24 at 0822 hours, showed Patient 3 was assessed for a pain level of 0 and the reassessment scale score was left blank.

On 9/17/24 at 1320 hours, a concurrent interview and review of Patient's 3 medical record was conducted with the CNO. The CNO reviewed the P&P and verified it applied to Patient 3. The CNO stated the expectation was for the patient to be assessed by the nursing staff for pain using the 1 to 10 pain scale as shown in the policy prior to receiving pain medication. The assessment was to be documented in the patient's medical record. The CNO stated the next step in the process was to provide the patient with pain relief in the form of the prescribed medication. The CNO also stated the nurse was expected to return and reassess the patient's pain after taking the pain medication to assess the effectiveness of medication and document the reassessment in the patient's medical record. The CNO reviewed Patient 3's medical record and verified the above documented notes and flowsheets. The CNO verified on 9/6/24, Patient 3 had an order for acetaminophen, and ibuprofen, both pain relievers. The CNO reviewed Patient 3's medical record, including the MAR, the times pain medications were given, the nursing progress notes, memos, and flow sheets on 9/6, 9/7, and 9/10/24.

On 9/17/24 at 1635 hours, the CNO, Director of Quality, and CEO were informed and acknowledged the findings.