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Based on record review and interview the facility failed to ensure that pain reassessments were completed in 1 hour after oral analgesic administration and that administration of analgesia was documented on pain flowsheet's per facility policy in 9 of 10 inpatient medical records reviewed (Patients #s 1, 2, 3, 4, 5, 7, 8, 9 & 10).

Findings include:

The facility policy titled "PAIN MANAGEMENT PLAN" # POC 7.56 last reviewed 3/8/18 was reviewed on 12/20/18. This document revealed "PROCEDURE: 1. a. The Registered Nurse performs a pain assessment during the patient admission assessment. Ongoing pain assessments and reassessments are performed by licensed nurses at least every shift, when a patient complains of pain and after an analgesic is given to determine effectiveness of the analgesic. Each pain assessment and reassessment will be documented in the patient medical record...c. Ongoing Assessments/Reassessments by licensed nursing staff: ii. Reassessment of pain is conducted through: 1) Evaluation and documentation of response to pain interventions. 2) Progress toward pain management goal including functional ability 3) Side effects of treatment 4) Risk factors for adverse events caused by the treatment...iv. Reassessment of pain relief interventions vary according to patient level of pain and patient status, pain relief interventions performed by the nurse and/or pharmacological agent administered and route of administration, nursing judgment and according to physician orders if present. 1) Recommended timeframe's for reassessment of effectiveness of pain relief may include: a) 30 minute reassessment-IM injection and IV medication b) 1 hour reassessment-oral medication and non pharmacological interventions."

Patient #1's medical record was reviewed on 12/20/18 at 2:15 PM. Patient #1 was admitted on 12/4/18 with a recent stroke with resulting fall. Patient #1's "Acceptable comfort level" was documented as a "5" on pain flowsheet. On 12/19/18 at 8:28 PM was documented as a "7" there was no documentation of analgesia given on pain flowsheet. There was a scheduled Tylenol documented as given at that time on the medication record. There was no documented reassessment of pain until 12/20/18 at 5:24 AM (9 hours later). On 12/19/18 at 8:32 AM was documented as a "7" there was no documented analgesia administered on pain flowsheet. There was a scheduled Tylenol documented as given at that time on the medication record. There was no documented reassessment of pain until 12:27 PM (4 hours later). On 12/18/18 at 4:39 PM was documented as "6-moderate-severe pain" there was no documented analgesia administered on pain flowsheet. There was a scheduled Tylenol documented as given at that time on the medication record. There was no documented pain eassessment until 7:31 PM (3 hours later). On 12/18/18 at 7:31 PM was documented as "10-excruciating pain" there was no documented analgesia administered on pain flowsheet. There was a scheduled Tylenol documented as given at that time on the medication record. There was no documented reassessment of pain until 11:52 PM (4 hours later). On 12/16/18 at 6:04 PM was documented as a "6-moderate-severe pain" there was no documented analgesia administered on pain flowsheet. There was a documented scheduled Tylenol at that time as well as a prn Lyrica documented at 7:14 PM on medication record. There was no documented reassessment of pain until 11:00 PM (5 hours later). On 12/15/18 at 5:57 PM was documented as "6-moderate-severe pain" there was no documented analgesia administered on pain flowsheet. There was a scheduled Tylenol documented as given at that time on the medication record. There was no documented reassessment of pain until 9:37 PM (3.5 hours later). On 12/15/18 at 2:55 AM was documented as a "8" there was no documented analgesia administered on pain flowsheet. There was a prn Tylenol documented as given at that time on the medication record. There was no documented reassessment of pain until 9:41 AM (6.5 hours later). On 12/14/17 at 12:27 PM was documented as "6-moderate-severe pain" there was no documented analgesia administered on pain flowsheet. There was a scheduled Tylenol documented as given at that time on the medication record. There was no documented reassessment of pain until 5:16 PM (5 hours later). On 12/13/18 at 4:50 AM was documented as a "8" there was no documented analgesia administered on pain flowsheet. There was a prn Tylenol documented as given at that time on the medication record. There was no documented reassessment of pain until 7:43 AM (2.5 hours later). On 12/11/18 at 7:30 AM was documented as "10" there was no documented analgesia administered on pain flowsheet. There was a scheduled Tylenol documented as given at that time on the medication record. There was no documented reassessment of pain until 10:30 AM (3 hours later). On 12/11/18 at 10:30 AM was documented as "9" there was no documented analgesia administered on pain flowsheet or medication record. There was no documented reassessment of pain until 9:21 PM (11 hours later). On 12/11/18 at 9:21 PM was documented as a "8" there was no documented analgesia administered on pain flowsheet. There was a scheduled Tylenol documented as given at that time on the medication record. There was no documented reassessment of pain until 12/12/18 at 12:41 AM (3 hours later). On 12/9/18 at 8:11 PM was documented as "6-moderate-severe pain" there was no documented analgesia administered on pain flowsheet. There was a scheduled Tylenol documented as given at that time on the medication record. There was no documented reassessment of pain until 12/10/18 at 6:21 AM (10 hours later). On 12/7/18 at 1:45 PM was documented as "8" there was no documented analgesia given on pain flowsheet. There was a scheduled Tylenol documented as given at 1:02 PM on the medication record. There was no documented reassessment of pain until 7:59 PM (6 hours later). On 12/7/18 at 1:35 AM was documented as "6" there was no documented analgesia given on pain flowsheet. There was a prn Tramadol documented as given at 12:36 AM on medication record. There was no documented reassessment of pain until 7:02 AM (5.5 hours later). On 12/6/18 at 1:01 PM was documented as "6-moderate-severe pain" there was no documented analgesia given on pain flowsheet. There was a scheduled Tylenol documented as given at that time on the medication record. There was no documented reassessment of pain until 7:07 PM (6 hours later).

Patient #2's medical record was reviewed on 12/20/18 at 2:00 PM. Patient #2 was admitted on 12/14/18 with a diagnosis of a fractured femur. Patient #2's "Acceptable comfort level" was documented as "4" on pain flowsheet. On 12/19/18 at 4:46 PM was documented as "8-severe pain" there was no documented analgesia administered on pain flowsheet. A prn (as needed) Hydrocodone (narcotic analgesic) was documented as administered at that time on the medication record. There was no documented reassessment of pain until 10:13 PM (5.5 hours later). On 12/18/18 at 4:15 AM was documented as "8" there was no documented analgesia administered on pain flowsheet. A prn Hydrocodone was documented as given at that time on the medication record. There was no documented reassessment of pain until 9:01 AM (3.5 hours later). On 12/18/18 at 9:39 PM was documented as "7" there was no documented analgesia administered on pain flowsheet. A prn Hydrocodone was documented as being given at 9:42 PM on medication record. There was no documented reassessment of pain until 12/19/18 at 8:51 AM (11 hours later). On 12/17/18 at 10:00 PM was documented as a "8" there was no documented analgesia given on the pain flowsheet. A prn Hydrocodone was documented as administered at that time on the medication record. There was no documented reassessment of pain until 12/18/18 at 4:15 AM (6 hours later). On 12/16/18 at 7:56 PM was documented as a "8-hurts whole lot" there was no documented analgesia given on pain flowsheet. A prn Hydrocodone was documented as given at that time on the medication record. There was no documented reassessment of pain until 12/17/18 at 8:06 AM (12 hours later). On 12/16/18 at 2:56 PM was documented at "8-hurts whole lot" there was no documented analgesia given on pain flowsheet. A prn Hydrocodone was documented as given at that time on the medication record. There was no documented reassessment of pain until 7:49 PM (4.5 hours later). On 12/16/18 at 7:53 AM was documented as "8-severe pain" there was no documented analgesia given on pain flowsheet. A prn Hydrocodone was documented as given at that time on the medication record. There was no documented reassessment of pain until 12:08 PM (4 hours later). On 12/15/18 at 5:40 AM was documented as "8" there was no documented analgesia given on pain flowsheet. A prn Hydrocodone was given at that time on the medication record. There was no documented reassessment of pain until 8:30 AM (3 hours later). On 12/15/18 at 4:29 PM was documented as "6-moderate-severe pain" there was no documented analgesia given on the pain flowsheet. A prn Hydrocodone was documented as administered at that time on the medication record. There was no documented reassessment of pain until 9:00 PM (4.5 hours later). On 12/15/18 at 9:14 PM was documented as "8" there was no documented analgesia given on pain flowsheet. A prn Hydrocodone was documented as given at that time on the medication record. There was no documented reassessment of pain until 12/16/18 at 2:45 AM (5.5 hours later).

Patient #3's medical record was reviewed on 12/20/18 at 4:50 PM. Patient #3 was admitted on 12/6/18 with a pathological fracture of the right hip. There was no documented "Acceptable comfort level" for Patient #3. On 12/19/18 at 9:21 AM was documented as "4-moderate pain" there was no documented analgesia given on pain flowsheet. A prn Morphine was given at that time on the medication record. There was no documented pain reassessment until 1:31 PM (4 hours later). On 12/18/18 at 7:38 PM was documented as "3" there was no documented analgesia given on pain flowsheet. A prn Morphine was documented as given at that time on the medication record. There was no documented pain reassessment until 12/19/18 at 8:02 AM (12 hours later). On 12/18/18 at 9:39 AM was documented as "4-moderate pain" there was no documented analgesia given on pain flowsheet. A scheduled Morphine was documented as given at that time on the medication record. There was no documented pain reassessment until 1:30 PM (4 hours later). On 12/17/18 at 9:35 AM was documented as "5" there was no documented analgesia given on pain flowsheet. A prn Roxicodone was documented as given at that time on the medication record in addition to a prn Morphine at 9:39 AM. There was no documented pain reassessment until 12:36 PM (3 hours later). On 12/16/18 at 8:13 PM was documented as "4" there was no documented analgesia given on pain flowsheet. A scheduled Morphine was documented as being given at that time on the medication record. There was no documented pain reassessment of pain until 12/17/18 at 4:55 AM (8 hours later).

Patient #4's medical record was reviewed on 12/20/18 at 1:30 PM. Patient #4 was admitted on 11/28/18 with a diagnosis of a spinal cord injury at C1-C4 with resulting quadriplegia. Patient #4's "Acceptable comfort level" was documented as "3". On 12/18/18 at 10:23 AM. There was no documented pain assessment again until 12/19/18 at 10:05 AM. On 12/6/18 at 8:52 PM was documented as having "6-moderate pain" there was no documented analgesia given on the pain flowsheet. There was a prn (as needed) Oxycodone (narcotic analgesic) documented as given on medication record at that time. There was no documented reassessment of pain until 12/7/18 at 7:52 AM (11 hours later). On 12/6/18 at 1:24 PM was documented as having "8-severe pain" there was no documented analgesia given on the pain flowsheet. There was a prn Oxycodone documented as given on medication record at that time. There was no documented reassessment of pain until 8:51 PM (7.5 hours later). On 12/5/18 at 7:28 PM was documented as having "6-moderate-severe pain" there was no documented analgesia given on the pain flowsheet. There was a prn Oxycodone given at 7:34 PM on medication record. There was no documented reassessment of the pain until 12/6/18 at 7:38 PM (12 hours later). On 12/5/18 at 7:21 AM was documented as having "4-moderate pain" there was no documented analgesia given on the pain flowsheet. There was a prn Oxycodone given at that time on medication record. There was no documented reassessment of pain until 10:34 AM (3 hours later). On 12/5/17 at 1:05 am was documented as having "4-moderate pain" there was no documented analgesia given on the pain flowsheet. There was a prn Oxycodone documented as given at 1:07 AM on medication record. There was no documented reassessment of pain until 7:21 AM (6 hours later). On 12/3/18 at 2:24 AM there was no documented pain assessment number on pain flowsheet and no documentation of analgesia given. On medication record for that time a prn Oxycodone was administered. There was no documented reassessment until 8:00 AM (5.5 hours later). On 12/3/18 at 12:07 PM there was no documented pain assessment number on pain flowsheet and no documentation of analgesia given. On medication record for that time a prn Oxycodone was administered. There was no documented reassessment until 8:45 PM (8 hours later). On 12/3/18 at 8:45 PM was documented as having "6-moderate-severe pain" at rest and "8-severe pain" with activity there was no documented analgesia given on the pain flowsheet. There was prn Oxycodone given at that time. There was no documented reassessment of pain until 12/4/18 at 4:06 AM (7 hours later). On 12/2/18 at 12:50 PM was documented as having "4-moderate pain" there was no documented analgesia given on the pain flowsheet. There was a prn Oxycodone documented as given at that time. There was no reassessment of pain until 4:45 PM (4 hours later). On 12/2/18 at 9:31 AM was documented as having "6" there was no documented analgesia given on pain flowsheet or medication record. There was no documented pain reassessment until 12:50 PM (2.5 hours later). On 12/2/18 at 12:22 AM was documented as having "4-moderate pain" there was no documented analgesia given on pain flowsheet. A prn Roxicodone was documented as given on medication record at that time. There was no documented reassessment of pain until 7:29 AM (7.5 hours later). On 12/1/18 at 10:31 AM was documented as having "4-moderate pain". A prn Roxicodone (narcotic analgesic) was documented as given at that time on pain flowsheet and medications record. There was no documented reassessment of pain until 9:00 PM (11 hours later). On 12/1/18 at 12:10 AM was documented as having "7" level of pain there was no documented analgesia given on pain flowsheet. A prn Roxicodone was documented as given on medication record at that time. There was no documented reassessment of pain until 9:00 AM (9 hours later). On 11/30/18 at 5:59 AM was documented as having "6-moderate-severe pain" at rest and "8-severe pain" with activity there was no documented analgesia given on pain flowsheet. A prn Roxicodone was given documented as given on medication record at that time. There was no documented reassessment of pain until 8:15 AM. On 11/29/18 at 9:04 PM was documented as having "4-moderate pain" at rest and "6-moderate-severe pain" with activity there was documented administration of analgesic. There was no reassessment of pain until 11/30/18 at 5:59 AM (8 hours later). On 11/29/18 at 1:20 AM there was documented analgesia administered and no documented pain assessment on pain flowsheet and no documented reassessment of pain until 9:04 PM (8 hours later).

Patient #5's medical record was reviewed on 12/20/18 at 2:45 PM. Patient #5 was admitted on 12/8/18 with a diagnosis of a Cerebral Vascular Accident (stroke). Patient #5's "Acceptable comfort level" was documented as "5". On 12/19/18 at 8:20 AM a "6" there was no documented analgesia given on pain flowsheet. There was no documented pain reassessment until 10:02 PM (14 hours later). On 12/18/18 at 1:54 AM was documented as having "6 moderate-severe pain" there was no documented analgesia given on pain flowsheet or medication record. There was no documented reassessment of pain until 7:29 PM (18 hours later). On 12/13/18 at 9:15 AM was documented as having "7" there was no documented analgesia given on pain flowsheet or medication record. There was no documented reassessment of pain until 10:35 PM (13 hours later). On 12/11/18 at 11:05 PM was documented as having "7" there was no documented analgesia given on pain flowsheet. There was scheduled Tylenol administered at that time on medication record. There was no documented reassessment of pain until 12/12/18 at 5:12 AM (6 hours later). On 12/11/18 at 4:00 PM was documented as having "6" there was no documented analgesia given on pain flowsheet. There was scheduled Tylenol administered at that time on medication record. There was no documented reassessment of pain until 11:05 PM (7 hours later). On 12/11/18 at 10:44 AM was documented as having "7" there was no documented analgesia given on pain flowsheet. There was scheduled Tylenol administered at that time on medication record. There was no documented reassessment of pain until 2:00 PM (3 hours later). On 12/10/18 at 4:01 PM was documented as having "6" there was no documented analgesia given on pain flowsheet. A prn Tylenol was documented as administered at that time on medication record. There was no documented reassessment of pain until 9:16 PM (5 hours later). On 12/9/18 at 9:19 PM was documented as having "7" there was no documented analgesia given on pain flowsheet. A prn Tylenol was administered at that time on medication record. There was no documented reassessment of pain until 12/10/18 at 8:27 AM (11 hours later). On 12/9/18 at 1:22 PM was documented as having "6-moderate-severe pain" there was no documented analgesia given on pain flowsheet. A prn Tylenol was administered at that time on medication record. There was no documented reassessment of pain until 8:00 PM (6.5 hours later). On 12/9/18 at 8:30 AM was documented as having "9" there was no documented analgesia given on pain flowsheet or medication record. There was no documented reassessment of pain until 12:50 PM (4 hours later).

Patient #7's medical record was reviewed on 12/20/18 at 1:30 PM. Patient #7 was admitted on 12/15/18 with a diagnosis of Brain Injury without open intracranial wound. Review of "Pain Flowsheet" revealed on 12/19/18 at 8:37 AM a pain assessment was completed. There was no documented pain assessment again until 12/20/18 at 2:00 AM (18 hours later). On 12/17/18 pain assessment was completed at 7:24 AM that documented "complains of pain/discomfort". There was no documented pain assessment again until 12/18/18 at 1:54 AM (30 hours later).

Patient #8's medical record was reviewed on 12/20/18 at 2:45 PM. Patient #8 was admitted on 12/10/18 with a diagnosis of Parkinson's disease. Pain flowsheet documented Patient #8's "Acceptable comfort level 3". Review of "Pain Flowsheet" on 12/19/18 at 12:52 AM was documented as having "6-moderate-severe pain" there was no documented analgesia given on pain flowsheet. A prn Tylenol was administered at that time on medication record. There was no documented reassessment of pain until 8:15 AM (7 hours later). On 12/18/18 at 2:44 AM was documented as having "8-hurts whole lot" there was no documented analgesia given on pain flowsheet. A prn Zanaflex (muscle relaxant) was documented as given on medication record at that time. There was no documented reassessment of pain until 10:00 AM (7 hours later). On 12/17/18 at 7:43 PM was documented ashaving "6-moderate-severe pain" with activity there was no documented analgesia given on pain flowsheet. A prn Zanaflex was documented as given on medication record at that time. There was no documented reassessment of pain until 12/18/18 at 2:44 AM (6 hours later). On 12/16/18 at 1:52 AM was documented as having "6-moderate-severe pain there was no documented analgesia given on pain flowsheet. A prn Zanaflex was documented as given on medication record at that time. There was no documented reassessment of pain until 12/17/18 at 5:09 AM (3 hours later). On 12/15/18 at 7:52 PM was documented as having "6-moderate-severe pain". A prn Zanaflex was documented as given on medication record at that time. There was no documented reassessment of pain until 1:52 AM (6 hours later). On 12/14/18 at 7:38 PM was documented as having "6-moderate-severe pain". A prn Zanaflex was documented as given on medication record at that time. There was no documented reassessment of pain until 12/15/18 at 7:30 AM (12 hours later). On 12/14/18 at 5:17 AM was documented as having "6" at rest there was no documented analgesia given on pain flowsheet. A prn Zanaflex was documented as given on medication record at that time. There was no documented reassessment of pain until 10:00 AM (4.5 hours later). On 12/14/18 at 3:00 AM was documented as having "6" there was no documented analgesia given on pain flowsheet or medication record. There was no documented reassessment of pain until 5:17 AM (2 hours later). On 12/14/18 at 12:50 AM was documented as having "7" there was no documented analgesia given on pain flowsheet or medication record. There was no documented reassessment of pain until 3:00 AM (2 hours later). On 12/13/18 at 5:14 AM was documented as having "6" there was no documented analgesia given on pain flowsheet or medication record. There was no documented reassessment of pain until 9:45 AM (4.5 hours later). On 12/12/18 at 4:06 PM was documented as having "6-moderate-severe pain" there was no documented analgesia given on pain flowsheet or medication record. There was no documented reassessment of pain until 7:00 PM (3 hours later). On 12/12/18 at 8:26 AM was documented as having "6-moderate-severe pain" there was no documented analgesia given on pain flowsheet. A prn Zanaflex was documented as given on medication record at that time. There was no documented reassessment of pain until 10:31 AM (2 hours later).

Patient #9's medical record was reviewed on 12/20/18 at 3:45 PM. Patient #9 was admitted on 12/6/18 with a diagnosis of a closed displaced fracture of pubis bone that occurred from a fall. "Pain Flowsheet" documented Patient #9's "Acceptable level of comfort" as a "3". On 12/19/18 at 8:29 AM was documented on "Pain Flowsheet" as having "6-hurts even more" there was no documented analgesia on the pain flowsheet. There was no documented reassessment of pain until 7:26 PM (13 hours later). On 12/14/18 at 1:22 PM was documented as having "8-severe pain" there was no documented analgesia given on pain flowsheet. A prn Tylenol was documented on medication record for that time. There was no documented reassessment of pain until 7:40 PM (6 hours later). On 12/11/18 at 8:37 PM was documented as having "8-severe pain" there was no documented analgesia given on pain flowsheet. A prn Tylenol was documented on medication record for that time. There was no documented reassessment of pain until 11:00 PM (2.5 hours later). On 12/6/18 at 7:55 PM was documented as having "6-moderate-severe pain" there was no documented analgesia given on pain flowsheet. A prn Tramadol was documented as given at that time on the medication record. There was no documented reassessment of pain until 12/7/18 at 7:15 AM (11.5 hours later).

Patient #10's medical record was reviewed on 12/20/18 at 1:45 PM. Patient #10 was admitted on 12/13/18 with a diagnosis of recent below knee amputation. "Pain Flowsheet" documented Patient #10's "Acceptable comfort level 4". On 12/19/18 at 9:06 AM was documented as having "level 6 moderate-severe pain" there was no documented analgesia on the pain flowsheet. There was a prn Oxycodone documented as given on medication record at that time. There was no documented reassessment of pain until 6:04 PM (9 hours later). On 12/16/18 at 10:23 PM pain rating documented as having "4 moderate pain" there was no documented analgesia given on the pain flowsheet. There was a prn Oxycodone documented as given on medication record at that time. There was no documented reassessment of pain until 12/17/18 at 3:58 AM (4.5 hours later). On 12/15/18 at 8:49 PM was documented as having "level 8 severe pain" there was no documented analgesia on the pain flowsheet. There was a prn Oxycodone documented as given on medication record at that time. There was no documented reassessment of pain until 12/16/18 at 9:12 AM (10 hours later). On 12/14/18 at 8:28 PM pain rating documented as having "5" there was no documented analgesia given on the pain flowsheet. There was a prn Oxycodone documented as given on medication record at that time. There was no documented reassessment of pain until 12/15/18 at 5:28 AM (7 hours later).

An interview was conducted with Chief Clinical Officer A on 12/20/18 at 3:30 PM who when asked what expectations were of nurses documentation on pain assessments and reassessments after analgesia replied "They should be charting a pain assessment atleast shiftly and then an hour after an oral analgesic is given a reassessment should be completed." When given pain flow sheet's and pointed out areas with prolonged reassessment times Chief Clinical Officer A stated "I am surprised. I would have expected there to be reassessments done sooner than they are."