Every finding on record at Lion Heart, Inc

It is required that the patient’s pain is assessed as part of a comprehensive assessment. The documented assessment of the patient’s pain includes: Characteristics of the pain, including: Location, frequency, and intensity; and How pain impacts the patient’s ability to engage in usual activities and function (e.g., appetite, sleeping). This standard was not met as evidenced by a review of clinical records. In 2 of 8 (25%) clinical records reviewed, documentation of the patients' pain in the initial comprehensive assessment did not include a full review of the characteristics and effect of the patients' pain. Clinical Record 0 - The initial pain assessment done by the RN on admission did not fully describe the patient's pain, including severity, characteristics, duration, intensity and effect on function. Clinical Record 3 - The initial pain assessment done by the RN on admission did not fully describe the patient's pain, including severity, characteristics, duration, intensity, and effect on function. Upon review of records it was found that the HIS documentation of the initial comprehensive pain assessments was not being completed.