HospitalInspections.org

Based on document review and interview the facility failed to ensure nursing staff followed a facility policy and physician order related to pain level reassessments for 1 of 10 patients (Patient #1).

Findings include;

1. Facility policy titled "(PCS.01.03.18) Pain Assessment and Management" with a revision date of 11/2025 indicated the following: III. STAFF RESPONSIBILITY: A...Clinical staff will conduct pain reassessment for relief from pain and/or responses to treatment.

2. A review of Patient #1's medical record indicated the following:

(a.) A physician order dated 8/29/25 at 9:43 p.m. indicated for nursing staff to reassess the patient's pain level within 1 hour of medication administration and re-treat as appropriate.

(b.) Review of the medication administration record indicated the patient was administered morphine 2 milligrams via IV (intravenous) push on 9/4/25 at 12:13 a.m. The patient had a FLACC pain score of 7 on 9/4/25 at 12:12 a.m. The medical record for Patient #1 lacked documentation of a pain level reassessment within one hour after the administration of the pain medication.

(c.) Review of the medication administration record indicated the patient was administered Oxycodone 40 milligrams 1 tablet ER (Extended Release) by mouth on 9/4/25 at 9:08 a.m. The medical record for Patient #1 lacked documentation of a pain level reassessment within one hour after the administration of the pain medication.

(d.) Review of the medication administration record indicated the patient was administered Oxycodone-Acetaminophen 10 milligrams-325 milligrams 1 tablet by mouth on 9/4/25 at 1:33 p.m. The medical record for Patient #1 lacked documentation of a pain level reassessment within one hour after the administration of the pain medication.

3. During a phone interview with N1 on 12/4/25 at 11:44 a.m., N1 indicated that (he/she) would assess/reassess and document a patient's pain level hourly.