HospitalInspections.org

Based on facility policy review, record review, and staff interviews, the facility failed to ensure staff adherence to a facility policy related to pain assessments for three patients (P) (P#1, P#2, and P#3) of three patients reviewed for pain., This failure increases the potential for improper pain management.


Findings included:


A facility policy titled "Pain Management," effective 11/30/2022, indicated, "The standard of [facility name] is to provide every patient with safe and effective pain management as a part of their plan of care." The policy also indicated, "The RN shall perform ongoing assessment and monitoring of the patient's pain." The policy noted, "Pain Reassessment 1. Pain reassessment is performed within one-hour [sic] of interventions. 2. For both pharmacological and non-pharmacological pain interventions, effectiveness of the intervention is evaluated through reassessment."


1. P#1's "H&P [History and Physical]" indicated the facility admitted the patient on 01/28/2025. According to the H&P, the patient had a medical history that included a chief complaint of acute respiratory failure with the need for ventilator weaning.


P#1's order for "acetaminophen (Tylenol) tablet 650 mg" was placed on 02/03/2025 at 3:24 p.m. and discontinued on 04/28/2025 at 12:12 p.m., due to the patient being discharged. The order revealed the frequency for administration was every six hours as needed (pro re nata; PRN).


P#1's "Medication Administrations" revealed the patient received 650 mg of acetaminophen on 03/02/2025 at 1:16 p.m.


P#1's "Pain Assessment" flowsheet lacked failed to reveal documentation showing the patient's pain was assessed or reassessed in association with the acetaminophen administration on 03/02/2025 at 1:16 p.m.


P#1's order for "oxyCODONE (Roxicodone) (an opioid analgesic used to treat moderate to severe pain) immediate release tablet 5 mg [milligrams]" every six hours PRN was placed on 01/28/2025 and discontinued on 04/28/2025 due to the patient being discharged.


P#1's "Medication Administration" revealed the patient received 5 mg of oxycodone on 03/06/2025 at 3:54 p.m.


P#1's "Pain Assessment" flowsheet failed to reveal documentation that the patient's pain was assessed or reassessed in association with the oxycodone administration on 03/06/2025 at 3:54 p.m.


P#1's "Medication Administrations" revealed the patient received 5 mg of oxycodone on 03/21/2025 at 11:51 p.m.


P#1's "Pain Assessment" flowsheet revealed no documentation that the patient's pain was assessed for the oxycodone administration on 03/21/2025 at 11:51 PM.


During an interview on 05/14/2025 at 10:51 a.m., Accreditation Manager (AM) #1 stated there was no pain assessment documented for the administration of acetaminophen or pain reassessment documented for P#1 on 03/02/2025 at 1:16 p.m.


During an interview on 05/14/2025 at 10:53 a.m., the Director of Patient Care Services (DPCS) stated there was no pain assessment or reassessment documented around the time of P #1's oxycodone administration on 03/06/2025 at 3:54 p.m.


During an interview on 05/14/2025 at 10:55 a.m., the DPCS stated that there was no pain assessment associated with Patient #1's oxycodone administration on 03/21/2025 at 11:51 PM.


2. P#2's "H&P [History and Physical]," dated 03/27/2025, revealed the patient was admitted due to a need for wound care and antibiotics.


P#2's order for "acetaminophen (Tylenol) tablet 650 mg" every 6 hours as needed (pro re nata; PRN) was placed on 03/27/2025 at 12:36 PM and discontinued on 04/07/2025 at 10:58 a.m.


P#2's "Medication Administrations" revealed the patient received acetaminophen 650 mg on 03/28/2025 at 1:52 p.m., 04/03/2025 at 7:30 p.m., 04/04/2025 at 9:12 a.m., 04/05/2025 at 8:35 a.m., 04/06/2025 at 5:30 a.m., and 04/07/2025 at 9:19 a.m.


P#2's "Pain Assessment" flowsheet lacked documentation of pain assessments or reassessments associated with the acetaminophen administrations on 03/28/2025 at 1:52 p.m., 04/03/2025 at 7:30 p.m., 04/04/2025 at 9:12 a.m., 04/05/2025 at 8:35 a.m., 04/06/2025 at 5:30 a.m., or 04/07/2025 at 9:19 a.m.


During an interview on 05/14/2025 at 10:39 a.m. the DPCS stated there were no pain assessments or reassessments documented for P#2's acetaminophen administrations that occurred on 03/28/2025 at 1:52 p.m.,, 04/03/2025 at 7:30 p.m., 04/04/2025 at 9:12 a.m., 04/05/2025 at 8:35 a.m.,, 04/06/2025 at 5:30 a.m.,, or 04/07/2025 at 9:19 a.m.


3. P#3's "H&P [History and Physical]," dated 04/01/2025, revealed the patient was admitted due to acute respiratory failure.


P#3's order for "acetaminophen (Tylenol) tablet 650 mg" every six hours as needed (pro re nata; PRN) was placed on 04/01/2025 at 3:04 p.m., and discontinued on 04/10/2025 at 11:13 a.m.


P#3's "Medication Administrations" revealed the patient received acetaminophen 650 mg on 04/05/2025 at 6:26 PM and 04/07/2025 at 8:48 p.m.


P#3's "Pain Assessment" flowsheet lacked documentation of pain assessments or reassessments associated with the acetaminophen administrations that occurred on 04/05/2025 at 6:26 PM and 04/07/2025 at 8:48 p.m.


During an interview on 05/14/2025 at 9:42 a.m., the DPCS stated Patient #3's flowsheet revealed no documented pain assessments or reassessments associated with the acetaminophen administrations that occurred on 04/05/2025 at 6:26 p.m. and 04/07/2025 at 8:48 p.m.


P#3's order for "oxyCODONE (Roxicodone) immediate release tablet 5 mg" every six hours PRN was placed on 04/01/2025 at 3:29 p.m., and discontinued on 04/10/2025 at 11:13 a.m.


P#3's "Medication Administrations" revealed the patient received oxycodone 5 mg on 04/03/2025 at 3:57 a.m., 04/04/2025 at 1:33 p.m., and 04/08/2025 at 9:49 p.m.


P#3's "Pain Assessment" flowsheet lacked documentation of pain assessments associated with the oxycodone administrations that occurred on 04/03/2025 at 3:57 a.m., 04/04/2025 at 1:33 p.m., or 04/08/2025 at 9:49 p.m.


During an interview on 05/14/2025 at 10:14 a.m., the DPCS stated there was no pain assessment documented for Patient #3's oxycodone administration on 04/03/2025 at 3:57 a.m., noting there was only documentation of a reassessment at 4:47 a.m., on 04/03/2025. She stated there was no pain assessment or reassessment for the administration of oxycodone on 04/04/2025 at 1:33 p.m., and stated there was no pain assessment for the oxycodone administration on 04/08/2025 at 9:49 p.m., noting there was a pain reassessment documented.