Volume 2025 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
16.01.02 Pain assessment and reassessment Frequency of the citation: 35%
16.02.02 Patients at risk Frequency of the citation: 29%
Overview of the requirement: Patient pain is managed through assessment, intervention, and reassessment. Policies and procedures identify standardized tools (pain scales) and define the means and frequency of monitoring. Comment on deficiencies: Compliance is evaluated through interviews and document review. Most deficiencies noted policies that did not require a quantitative or visual analog scale as a measurement for pain. Reassessment after medication administration was another frequent citation. Examples of ACHC Surveyor findings: ■ Records reviewed lacked evidence of a qualitative reassessment for pain after medication administration. Records lacked identification of a pain location as required by hospital policy. Records indicated Tylenol for pain; but pain was documented as zero in the medical record. ■ The hospital’s pain management policy requires a quantitative pain reassessment after the intervention has reached peak effect and documented evaluation and response within specific time frames. Medical records in the ICU lacked documentation of the effect of PRN pain medications. Medical records in the telemetry unit lacked reassessment after IV dantrolene PRN. ■ Records lacked a quantitative pain reassessment after pain medication administration. ■ ED patient records lacked documentation of a pain reassessment after administration of Toradol 30 mg IM. The hospital’s policy states, "reassessment must be completed within an hour." ■ ED records documenting patient pain levels of 5 and 6 had no additional documentation of actions taken to address the pain.
Overview of the requirement: The hospital assesses patients for risk of pressure ulcers, DVT, aspiration, malnutrition, and falls. Comment on deficiencies: Compliance is evaluated through document review. Deficiencies noted policies and records that were inadequate with regard to required assessments, either missing specific elements or failing to define actions taken based on the results of the assessment. Examples of ACHC Surveyor findings: ■ Hospital admission policies lacked the required risk assessment and reassessment for DVT/VTE. ■ DVT/VTE risks were documented, and patients were placed in low, medium, or high-risk categories. Interventions do not change with medium or high-risk categories (ambulation, SCDs and TED hose. Interventions do not include the need for a review of anticoagulation usage. ■ Three out of five nursing assessments reviewed lacked the fall risk assessment defined in hospital policy.
Compliance tips for:
The medical complications associated with risks identified in this standard are avoidable with proactive assessment. An admission assessment policy is expected to include the five items with a process of intervention to be implemented for at-risk patients. ■ Review policy for inclusion of all required elements. ■ Audit medical records for the presence of assessment results at admission and periodically (as defined by the hospital) during a patient stay.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Compliance tips for:
Patients have a right to pain management. This standard requires consistent use of a standardized pain scale tool appropriate to the age and condition of the patient. Assessment is followed by medication and/or non-medication interventions and subsequent reassessment for effectiveness. ■ Review policies for inclusion of all required elements. ■ Audit patient records to confirm compliance with assessment and reassessment requirements. ■ Train staff to use the appropriate pain scale and the defined frequency based on the intervention chosen.
Nerd Newbies (understand the requirement)
■ Ensure annual review of the Falls Prevention Program.
Nerd Trailblazers (prepare the path for others)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
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