Accreditation Audit AFT Task 1 Carol Gore 4/6/2014

A. Compliance Status PC .01.01.07 Pain is assessed in all patients (The Joint Commission, 2013) Finding: In outpatient rehabilitation, the initial assessment of pain does not indicate the severity of the pain, making assessment of the relief of pain as a result of treatment difficult. The facility failed to be compliant with this element of performance by not appropriately assessing the patients pain, or by having and following a comprehensive pain assessment process that is specific to each patient on an individual basis. Patients should be assessed and reassessed for pain based on their condition and their perception of their pain. Failure to assess each patient as an individual based on their perception fails this standard. A1. Plan for Compliance 1) Develop and educate staff to pain management policy by 4/15/2014 2) Consider pain as a fifth vital sign and educate staff by 4/15/2014 3) Assess patients pain upon admission using 0-10 pain scale(zero being no pain and 10 being worst pain ever) 4) Assess pain every two hours asking patient to rate pain on a scale of 0-10 5) If patient has pain upon assessment, provide pain medications as ordered (Reassess pain every 30 minutes after IV medication and 1 hours after oral medications) Continue to reassess every two hours thereafter 6) Perform weekly chart audits to ensure compliance and report results in Quality Council monthly meeting to measure success of plan. A2. Justification Pain management is a top priority for patients that receive hospital care. Pain management or lack thereof will impact the recovery process for the patient not to mention the perception they will have of the hospital. Pain management is now a key focus for all hospitals in regards to pay for performance initiative that are instrumental to all hospitals as we evolve through the current healthcare environment. Patient recovery hinges on the hospitals ability to manage their pain to an acceptable level during their hospital stay. B. Sources (The Joint Commission, 2013)