Paradise Valley Hospital

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 50175 Based on interview and record review, the facility failed to ensure policies were followed when: 1. Pain was not assessed for two of 30 patients (Patient 25 and Patient 28) sampled for pain assessment. 2. A signature page indicating discharge instructions were reviewed, were missing signatures for two of 15 sampled patients (Patient 16 and Patient 30) who were discharged. Findings: 1. (a) Patient 25 was admitted to the facility on 1/6/26 with diagnoses which included end stage renal disease (kidney disease) and chronic (long-term) pain, per the history and physical (a physician’s initial assessment). A concurrent interview and review of Patient 25’s medical record was conducted on 1/8/26 at 8:57 A.M. with Director of Nursing (DON) and Nurse Manager (NM) 18. An order for vital signs every four hours was ordered by a physician on 1/5/26 at 11:57 P.M. Patient 25’s vital signs were documented as taken on 1/8/26 at 5:49 A.M. and 7:45 A.M. There were no pain assessments documented on 1/8/26 between 1:30 A.M. and 10:26 A.M. DON acknowledged there were no pain assessments documented on 1/8/26 between 1:30 A.M. and 10:26 A.M. DON stated that pain assessment was a part of the vital signs. DON stated it was important to assess pain in order to intervene timely. A review of the facility’s policy titled Pain Management, last reviewed 1/2025, indicated “ ...Assess for pain ...with routine vital signs and PRN [as needed] ...” (b) Patient 28 was admitted to the facility on 12/9/25 with diagnoses which included pleural effusion (fluid in the lungs) and chronic obstructive pulmonary disease (COPD; lung disease), per the face sheet. A concurrent interview and review of Patient 28’s medical record was conducted on 1/8/26 at 10:48 A.M. with Director of Nursing (DON) and Nurse Manager (NM) 18. An order for vital signs every four hours was ordered by a physician on 12/9/25 at 9:53 A.M. Pain assessments for Patient 28 were not documented from 12/10/25 at 7:29 P.M. until 12/11/25 at 8:42 A.M. DON acknowledged there was no documentation from 12/10/25 at 7:29 P.M. until 12/11/25 at 8:42 A.M. DON stated it was important to assess pain with vital signs, to do a full assessment and to intervene timely if needed. A review of the facility’s policy titled Pain Management, last reviewed 1/2025, indicated “ ...Assess for pain ...with routine vital signs and PRN [as needed] ...” 2. (a) Patient 16 was admitted to the facility’s Emergency Department (ED) on 11/16/25 for a fall and left hip pain, per the face sheet. A review of Patient 16’s medical record was conducted on 1/6/26 at 1:07 P.M. with Chief Nursing Officer (CNO), Director of Performance Improvement (DPI), and Director of Nursing (DON). Patient 16 arrived to the ED on 11/16/25 at 8:51 P.M., and was discharged on 11/17/25 at 12:25 A.M., per the visit summary record. The discharge instructions signature page did not include a signature designated for Caregiver/RN/Doctor signature, nor was it dated or timed. An interview with CNO was conducted on 1/6/26 at 1:53 P.M. CNO stated the discharge instructions signature page should be signed by the nurse who gave the discharge instructions. CNO stated that signing the signature page indicated a “two-way communication” between Patient 16 and the nurse, and was an “attestation” that discharge instructions were reviewed. An interview with Licensed Nurse (LN) 18 was conducted on 1/7/26 at 1:25 P.M. LN 18 stated that the discharge signature page should be signed by the nurse to show discharge instructions were given by the nurse. LN 18 stated it was his usual practice to sign the signature page after the patient signed the signature page. LN 18 stated he did not know why the signature page was missing a nurse’s signature. A review of the facility’s policy and procedure titled Discharge of Patient, last reviewed 10/2023, indicated “ ...Initiator of Action ...RN [Registered Nurse], LVN ...Complete the Discharge Summary and Patient Instruction form ...” A review of the facility’s policy and procedures titled Completion of Medical Records, last reviewed 10/2023, indicated “ ...PURPOSE: Timely completion of medical records, with entries authenticated, legible, and complete ...Completion, Timeliness, and Authentication of Medical Records ...all entries must be authenticated legibly by the author ...all entries in the medical record must be dated and timed ...” (b) Patient 30 was admitted to the facility’s Emergency Department (ED) on 11/28/25 for abdominal (stomach) pain, per the face sheet. A review of Patient 30’s medical record was conducted with Director of Nursing (DON) and Nurse Manager 19 on 1/8/26 at 11:47 A.M. Patient 30 arrived in the ED on 11/28/25 at 11:35 P.M., and was discharged on 11/29/25 at 3:55 A.M., per the visit summary record. DON could not locate a discharge signature page in Patient 30’s electronic or paper record. DON stated there should be a discharge signature page because it was part of the discharge process. A review of the facility’s policy and procedure titled Discharge of Patient, last reviewed 10/2023, indicated “ ...Initiator of Action ...RN [Registered Nurse], LVN ...Complete the Discharge Summary and Patient Instruction form ...” A review of the facility’s policy and procedures titled Completion of Medical Records, last reviewed 10/2023, indicated “ ...PURPOSE: Timely completion of medical records, with entries authenticated, legible, and complete ...Completion, Timeliness, and Authentication of Medical Records ...all entries must be authenticated legibly by the author ...all entries in the medical record must be dated and timed ...””

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 45063 Based on interview and record review, the facility failed to ensure pain medication administration policy was followed when one randomly reviewed patient (2) did not receive pain medication per the physician’s (MD) order, based on the pain scale assessment. This failure had the potential to result in ineffective pain management for Patient 2. Findings: Patient 2 was admitted to the facility on 11/24/25 with a medical history which included left foot wound, anxiety (feeling of apprehension and fear accompanied by physical symptoms that interferes with daily life) and diabetes (chronic condition where the body has high blood sugar and not enough insulin to respond), per Patient 2’s History and Physical (H&P). During a review of Patient 2’s Medication Orders dated 11/24/25, Patient 2 had orders for : “Morphine Sulfate (pain medication) 2 (two) mg (milligrams)/IVP (intravenous push; given directly into a vein via a needle or catheter), for severe pain level (7-10), Hydrocodone (pain medication) 5-325 mg, 2 tabs (tablets) every 4 (four) hours PO (given by mouth) for moderate pain level (4-6), Tylenol (pain medication) 650 mg every 4 hours PO for pain level (1-3 )...” During a concurrent interview and record review on 1/7/26 at 10:40 A.M. with the Director of Performance Improvement (DPI), the DPI referred to Patient 2’s Medication Administration Record (MAR) dated November 2025, and stated that Patient 2 was given Hydrocodone PO for a pain level of 7 out of 10, on 11/24/25 on three occasions: 8:46 A.M., 1:51 P.M., and 9:03 P.M. The DPI stated that Patient 2 should have received Morphine 2 mg/ IVP for the pain level of 7 out of 10, per MD’s orders and the pain scale assessment. The DPI acknowledged that Patient 2 receiving the right pain medications based on his pain scale were important for patient safety and effective pain management. The facility’s policy and procedure (P&P) titled, “Pain Management” dated January 2025 indicated, “Procedure ...2. Pain intensity will be assessed using ...2.4. Numeric Pain Intensity Scale a. None, Mild (1-3), Moderate (4-6), severe (7-10 ...) 5. Pharmacologic pain management will be provided to patients by physician order ...””

“PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS CFR(s): 482.13(d) Patient Rights: Confidentiality of Records This Standard is not met as evidenced by: 45909 Based on observation, interview and record review, the facility failed to ensure the patients’ privacy and confidentiality were protected when the patients’ identification/arm bands (bracelet with patient’s name, age, date of birth) were taped outside the patients’ door for two of 30 sampled patients (Patient 23 and 24). This failure had the potential to expose the patients’ private information to unauthorized individuals. Findings: During an observation conducted on 1/29/24 at 9:50 A.M. with the DIR-SURG in the fifth-floor hallway. Patient 23 and Patient 24’s identification/arm bands were observed taped outside the patient’s door. An interview was conducted on 1/29/24 at 9:56 A.M., with RN 23. RN 23 stated the patients arm bands should have not been taped outside the patients’ door to prevent possible exposure of patients’ private information to unauthorized individuals. During an interview on 1/29/24 at 1:22 P.M.,with CN 24. CN 24 stated patients’ arm bands were not to be displayed where unauthorized individuals can access the patients’ private information. An interview was conducted on 1/31/24 at 1:38 P.M., with the DON. The DON stated nursing staff should place the arm bands on the wrist of the patients where only authorized individuals can access the information. The DON stated the patients’ arm bands should have not been taped on the patients’ door to protect the patient’s information. A review of the facility’s policy titled, Confidentiality: Patient Status, reviewed 10/23. The policy indicated “CONFIDENTIAL STATUS: PATIENTS 1.1 Patients are placed on confidential status:..e. No information regarding name, bed/room assignment is made to the public...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 43674 Based on interview and record review, the facility did not ensure the staff followed restraint (a method to immobilize an individual) policy and procedure for two of 30 sampled patients (Patient 7 and 8) when: 1. Patient 7 was restrained without an order and 2. Patient 8 was restrained with an incomplete order. This failure resulted to Patient 7 placed on restraint with an expired order, and Patient 8 placed on restraint without determining the duration. Findings: 1. Patient 7 was admitted on 1/13/24 with diagnoses which included subdural hematoma (brain bleed) per the patient’s History and Physical dated 1/13/24. A concurrent interview and record review on 1/31/24 at 10:17 A.M., with CN 7, the DIR-SURG, and the DIR-RESP were conducted. Patient 7’s restraint orders dated 1/15/24 and 1/16/24, and Medical Restraint Flowsheet dated 1/16/24 were reviewed. The physician order dated 1/15/24 indicated the restraint order was to expired on 1/16/24 at 8 A.M. The physicians’ order was not renewed until 5 P.M. on 1/16/24. The document titled Medical Restraint Flowsheet indicated, Patient 7 was on restraints from 8 A.M., until 12:45 P.M., on 1/16/24. The DIR-SURG stated, Patient 7’s restraint order should have been renewed on 1/16/24 at 8 A.M. The DIR-SURG further stated, Patient 7 should have not been put on restraint on 1/16/24 from 8 A.M. to 12:45 P.M.,without a physician’s restraint order. CN 7 stated the restraint orders should have been reviewed to ensure Patient 7 had a valid and an unexpired restraint order. The DIR-RESP stated it was important to ensure there was a physician order before patients were placed on restraints for safety and legal reasons. During a review of the hospital’s policy and procedure titled, Use of Restraints and/or Seclusion, last reviewed 7/2022 indicated, “...POLICY...13. Requirement for orders for behavior management/restraints/seclusion...13.2. A verbal order or written order must be obtained from physician within one hour following the initiation of restraint/seclusion...” 2. Patient 8 was admitted on 1/15/24 with diagnoses which included per the patient’s History and Physical dated 1/15/24. During a concurrent interview and record review on 2/1/24 at 9:54 A.M., with CN 8 and DIR-RESP, Patient 8’s restraint orders dated 1/25/2024 to 1/31/2024 were reviewed. The physician restraint orders dated 1/26/24 did not include the start time for the restraints. CN 8 stated the restraint orders should have had a start date and time. During a concurrent interview and record review on 2/1/24 at 2 P.M., with the CNO, Patient 8’s restraint orders dated 1/25/2024 to 1/31/2024 were reviewed. The CNO stated the elements of the restraint order were incomplete. The CNO stated, the restraint order dated 1/26/24 did not have a start time. The CNO stated it was important the restraint order had the complete details including the start time. During a review of the hospital’s policy and procedure titled, Use of Restraints and/or Seclusion, last reviewed 7/2022, indicated, “...POLICY...12. Requirement for orders for medical and surgical restraints...12.2. Each order for the restraint must be time limited and shall not exceed the time limitation respective to the reason for restraint.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 43674 Based on interview and record review, the facility failed to ensure the staff consistently assessed and monitored two of 30 sampled patients (Patient 7 and 8) on restraints. This failure had the potential to result in patient injury and compromised safety. Findings: 1. Patient 7 was admitted on 1/13/24 with diagnoses which included subdural hematoma (brain bleed) per the History and Physical dated 1/13/24. A concurrent interview and record review on 1/31/24 at 2:45 P.M., with CN 7, the DIR-SURG and the DIR-RESP were conducted. Patient 7’s medical restraint flowsheet dated 1/13/2024 to 1/18/24 was reviewed. Patient 7’s restraint assessment and monitoring every 2 hours were not documented on the following dates: 1/15/24 8 P.M. 1/16/24 8 A.M., 10 A.M., 12 P.M. 1/17/24 at 12 P.M. CN 7 stated the staff should have documented the restraint monitoring every 2 hours. 2. Patient 8 was admitted on 1/15/24 with diagnoses which included altered level of consciousness (change in level of alertness and consciousness) per the History and Physical dated 1/15/24. A concurrent interview and record review on 2/1/24 at 9:54 A.M., with CN 8 and the DIR-RESP were conducted. Patient 8’s medical restraint flowsheet dated 1/25/24 to 2/1/24 was reviewed. The medical restraint flowsheet indicated, Patient 8’s restraint assessment and monitoring every 2 hours were not documented on the following dates: 1/26/24 10 A.M. 1/29/24 8 A.M., 10 A.M., 12 P.M., 2 P.M. and 6 P.M. 2/1/24 6 A.M. The DIR-RESP stated the staff should have documented the restraint monitoring every 2 hours. During a review of hospital policy and procedure titled, Use of Restraints and/or Seclusion, last reviewed 7/2022, indicated, “POLICY...15. Reassessment and monitoring of the patient in restraint and seclusion...15.3 Acute medical and surgical restraints...a. Patients will be assessed at least every two (2) hours or more frequently if necessary...””

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 43674 Based on interview and document review, the facility failed to implement its staffing plan policies for the Medical/Surgical and Telemetry (continuous remote monitoring of patient’s heart rate and rhythm) units. This had the potential to put patients at increased safety risk, delay of care, and cause decline in their condition. Findings: During a review of hospital’s policy and procedure titled, Patient Classification System Acuity last reviewed 7/2021, indicated, “...POLICY 1. California Department of Public Health (CDPH) staffing ratios will be used as a minimum staffing level on units...1.4. Med/Surg 5:1...” During an interview on 1/29/24 at 1:15 P.M. with LVN 7, LVN 7 stated the RN provided over all supervision to the LVN’s assigned patients. During an interview on 1/30/24 at 9:54 A.M., with RN 7, RN 7 stated the supervision of the LVN’s patients was an additional RN responsibility. RN 7 stated the total patient assignment she was responsible for was her current patient assignment in addition to the LVN’s patients. RN 7 stated that meant she was out of the nurse-to-patient ratio. RN 7 stated, it was important to be in nurse-to-patient ratio for patient safety and timely provision of care. During an interview on 1/30/24 at 10:12 A.M. with RN 8, RN 8 stated the CN provided breaks to the RNs and LVNs. Per RN 8, the CN had the RN’s assigned patients in addition to the LVN’s assigned patients when RNs go on break. During a concurrent interview and record review on 1/30/24 at 1:44 P.M., with the DON, the Medical/Surgical unit staff assignment from 1/1/24 to 1/29/24 was reviewed. The Medical/Surgical unit staff assignment indicated the unit was not on 5:1 nurse-to-patient ratio when RNs had 6 patients (5 assigned patient and 1 supervised LVN patient), Charge Nurse had 10 patients while providing lunch breaks to the RNs (5 RN patients and 5 supervised LVN patients), and RNs were assigned 6 patients during the shift, on the following dates: Night shift: 1/4, 1/5, 1/7, 1/8, 1/9, 1/20, 1/21, 1/26, 1/27/24 Day shift: 1/5, 1/9, 1/12, 1/13, 1/17, 1/18, 1/24, 1/26, 1/28 and 1/29/24 The DON stated the supervising RN was the responsible staff for the over all care of the LVN’s patients. The DON stated the RN had five patients and supervised one LVN’s patient which made the RN having a total of 6 patients. The DON stated the RN was out of the nurse-to-patient ratio. In addition, the DON stated when the CN provided breaks to an RN with five patients and with a supervised LVN, the CN had a total of 10 assigned patients during the duration of the RN’s breaks. The DON stated the CN was out of the nurse-to-patient ratio.The DON stated the importance of being in ratio was for patient safety, the ability to manage the patient load safely, and be able to provide optimal care when working with the patients. During an interview on 2/1/24 at 8:30 A.M. with the CNO, the CNO stated it was important to be in compliance with nurse-to-patient ratio for patient safety. 45909 During a review of hospital’s policy and procedure titled, Patient Classification System Acuity last reviewed 7/2021, indicated, “...POLICY 1. California Department of Public Health (CDPH) staffing ratios will be used as a minimum staffing level on units...1.2. Telemetry 4:1...” During a concurrent interview and record review on 1/30/24 at 1:22 P.M. with CN 24. Review of the TDSAS dated 1/12/24 and 1/25/24, indicated, during the nocturnal shift (7 P.M. to 7 A.M.), the LNs were assigned five patients each which was out of the nurse-to-patient ratio. CN 24 stated, a telemetry unit LN should have four patient’s assignment per shift. CN 24 stated the LNs should have not been assigned more than four patients to ensure efficient patient care was provided. CN 24 stated, the LNs exceeded the nurse-to-patient ratio of four patients and may affect the care of the patients. An interview was conducted on 1/31/24 at 1:38 P.M., with the DON. The DON stated licensed nurses in the telemetry unit should not have more than four patients to provide a more efficient nursing care and safety to the patients. The DON stated the importance of the nurse-to-patient ratio was for patient safety, the ability to manage the patient load safely, and be able to provide optimal care when working with the patient.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 45909 Based on interview and record review, the facility failed to ensure the RN validated (rechecked with signature) the accuracy of the LVN’s nursing assessment (patient’s ongoing health status) for four out of 30 sampled patients (Patients 23, 25, 26, 27). This failure had the potential to affect the care and well-being of the patients. Findings: A concurrent interview and record review were conducted on 01/31/24 at 9:22 A.M., with RN 24. RN 24 stated, on the night shift of 1/26/24, LVN 24’s nursing assessment documentation on Patients 23, 25, 26 and 27 were not validated by a RN. RN 24 further stated LVN 24’s assessment documentation should have been validated by a RN to ensure the accuracy of information entered. During an interview on 1/31/24 at 11:04 A.M., with the unit CN 25. CN 25 stated, the RN should have validated the LVN’s nursing assessment to ensure the LVN documentation was accurate and applicable to the nursing care provided. An interview was conducted on 1/31/24 at 1:38 P.M., with the DON. The DON stated, the RN was responsible in validating the LVN’s nursing assessment. The DON stated, the RN should have validated the LVN’s documentation to ensure proper care and safety were provided to patients. Review of the facility’s policy, Scope of Practice, Nursing Personnel dated 10/2023, indicated. “POLICY:..2. RNs are responsible for the coordination of aspects of care to include assessment, planning care, delegating tasks....””

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 38542 Based on interview and record review, the facility failed to ensure nursing care plans were developed for two of 30 sampled patients (Patient 1 and 2). This failure had the potential for delay in providing care. Findings: 1. Patient 1 was admitted to the facility on 1/28/24 with diagnoses which included symptomatic bradycardia (low heart rate) per the facility’s Administration/Registration sheet. On 1/31/24 at 9:40 A.M., a joint interview and review of Patient 1’s records with the MGR-ICU was conducted. Per the laboratory results on 1/28/24 at 4:10 A.M., and 9:39 A.M., Patient 1 had a hemoglobin (Hgb-low amount of red blood cells to carry oxygen to the organs of the body) level of 6.2 (low) and 6.7 (low), respectively. There was no documentation a care plan was developed for this condition. The MGR-ICU stated there should have been a care plan initiated for “anemia” (low Hgb) for Patient 1. 2. Patient 2 was admitted to the facility on 1/28/24 with diagnoses which included sepsis (blood infection) per the facility’s Administration/Registration sheet. On 1/31/24 at 10:25 A.M., a joint interview and a review of Patient 2’s records with the MGR-ICU was conducted. There was no evidence of documentation a care plan was developed for sepsis. The MGR-ICU stated there should have been a care plan for sepsis or infection developed for Patient 2. The MGR-ICU stated patient care plans should have been initiated on admission and anytime there was a patient care or need. Per the facility’s policy and procedure titled Nursing Care Plan- Interdisciplinary, last reviewed 7/2021, “PURPOSE: To ensure that a Plan of Care is developed for each patient that is individualized to meet the patients’ unique needs...””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 38542 Based on interview and record review, the facility failed to ensure nursing staff followed policy and procedure for one of 30 sampled patients (Patient 2) when: 1) a pain medication was not administered in a timely manner and 2) pain reassessment was not conducted in a timely manner As a result, there was a potential Patient 2’s pain was not relieved. Findings: Patient 2 was admitted to the facility on 1/28/24 with diagnoses which included sepsis (blood infection) per the facility’s Administration/Registration sheet. 1) On 1/31/24 at 10:25 A.M., a joint interview and record review with the MGR-ICU was conducted. Per the Vital Signs/Pain Management- Pain Assessment flowsheet, on 1/30/24 at 8 P.M., Patient 2 had a pain score of 8 (0-no pain, mild 1-3, moderate 4-6, severe 7-10) located in the abdomen with an acceptable pain level of 3. Per the MAR, pain medication was administered at 8:52 P.M. The MGR-ICU stated the staff left Patient 2 with “severe” pain for almost one hour without addressing it. On 1/31/24 at 10:42 A.M., an interview with the DON was conducted. The DON stated pain medication should have been given timely for the patient’s comfort. Per the facility’s policy and procedure titled, Pain Management, last reviewed on 7/2021, “POLICY:..respects and supports the rights of patients to safe, timely and effective pain management ...” 2) On 1/31/24 at 10:25 A.M., a joint interview and record review with the MGR-ICU was conducted. Per the Vital Signs/Pain Management- Pain Assessment flowsheet, on 1/30/24 at 8 A.M., Patient 2 had a pain score of 8 on the numeric pain intensity scale (0-no pain, mild 1-3, moderate 4-6, severe 7-10) located in the abdomen with an acceptable pain level of 3. Per the MAR, pain medication was administered at 8:09 A.M., and reassessment of the current level of pain was conducted at 12 P.M. The MGR-ICU stated Patient 2’s pain level should have been reassessed within one hour of pain medication administration to ensure Patient 2’s pain was properly addressed and the intervention was effective. On 1/31/24 at 10:56 A.M., an interview with RN 1 was conducted. RN 1 stated she was not aware of the policy as to when the patient’s pain should be reassessed after medication administration. On 1/31/24 at 2:46 P.M., an interview with RN 2 was conducted. RN 2 stated pain reassessment should have been conducted within 30 minutes to 1 hour after medication administration to check if the pain level improved or not. Per the facility’s policy and procedure titled, Pain Management, last reviewed on 7/2021, “...PROCEDURE:..1.5. After each pain management intervention...the goal is reassessment and documentation within 1 hour of intervention...””