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A. Based on a review of LTAC policy, medical record review, and staff interview, it was determined in 6 of 7 (Pts #1, #2, #3, #5, #6, #7) medical records reviewed, the LTAC failed to ensure a pain assessment was conducted at the time of pain medication (IV and/or PO) administration, in accordance with its policy.
Findings include:

1. The policy titled "Pain Management Plan" was reviewed on 7/23/13. It indicated "V. A. Ongoing Assessments: 1. Pain is to be assessed at least every shift with the shift assessments and when as needed analgesic is given."

2. The medical record of Pt #1 was reviewed on 7/23/13. Pt #1 was admitted to the LTAC on 5/28/13 with the diagnosis Acute Respiratory Failure. On 5/28/13, there was a physician order "Norco 7.5/325 mg one every 6 hours as needed" and on 5/29/13, the dose was increased to 2 tablets every 6 hours as needed. Between 5/28/13 and 6/1/13, 3 out of 14 doses administered failed to include a pain assessment at the time of PO pain medication administration. On 5/29/13, there was a physician order "Morphine 3 mg IV every 3 hours as needed." Between 5/29/13 and 6/1/13, 7 out of 14 doses administered failed to include a pain assessment at the time of IV pain medication administration.

3. The medical record of Pt #2 was reviewed on 7/24/13. Pt #2 was admitted to the LTAC on 6/20/13 with the diagnosis Acute Respiratory Failure. On 6/20/13, there was a physician order Norco 10/325 mg one every 6 hours as needed." This was discontinued on 6/26/13. On 7/16/13, there was a physician order "Norco 10/325 mg one every 4 hours as needed." As of 7/24/13 at 1:00 PM, 5 out of 27 total doses administered failed to include a pain assessment at the time of PO pain medication administration.

4. The medical record of Pt #3 was reviewed on 7/24/13. Pt #3 was admitted to the LTAC on 7/2/13 with the diagnosis Acute Respiratory Failure. On 7/5/13, there was a physician order "Fentanyl 25 mcg IV every 6 hours as needed." This was discontinued on 7/11/13. Between 7/5/13 and 7/11/13, 1 out of 1 dose given failed to include a pain assessment at the time of IV pain medication administration. On 7/11/13, there was a physician order "Norco 5/325 mg by mouth every 6 hours as needed." As of 7/24/13 at 2:30 PM, 2 out of 5 doses given failed to include a pain assessment at the time of PO pain medication administration.

5. The medical record of Pt #5 was reviewed on 7/24/13. Pt #5 was admitted to the LTAC on 6/26/13 with the diagnosis Acute Respiratory Failure. On 6/26/13, there was a physician order "Norco 5/325 mg one every 6 hours as needed." As of 7/24/13 at 2:00 PM, 4 out of 8 doses failed to include a pain assessment at the time of PO pain medication administration.

6. The medical record of Pt #6 was reviewed on 7/24/13. Pt #6 was admitted to the LTAC on 7/3/13 with the diagnosis Pneumonia. On 7/4/13, there was a physician order "Norco 5/325 mg every 6 hours as needed." As of 7/24/13 at 1:30 PM, 14 out of 40 doses failed to include a pain assessment at the time of PO pain medication administration.

7. The medical record of Pt #7 was reviewed on 7/24/13. Pt #7 was admitted to the LTAC on 7/19/13 with the diagnosis Open Wound Site Nos- Comp. On 7/19/13, there was a physician order "Hydromorphone 1 mg IV every 8 hours as needed." As of 7/24/13 at 2:20 PM, 1 out of 5 doses given failed to include a pain assessment at the time of IV pain medication administration. On 7/19/13, there was a physician order "Norco 10/325 mg one every 4 hours as needed." As of 7/24/13 at 2:20 PM, 2 out of 10 doses failed to include a pain assessment at the time of PO pain medication administration.

8. During a staff interview, conducted with the RN Supervisor on 7/23/13 at 2:00 PM, it was verbalized that "There is to be a pain assessment prior to every administration of PO and IV pain medications." It was confirmed that the medical records of Pts #1, #2, #3, #5, #6, #7 failed to include a pain assessment at the time of either PO or IV medication administration.

B. Based on a review of LTAC policy, medical record review, and staff interview, it was determined in 4 of 5 (Pts #1, #2, #3, #7) medical records reviewed, the LTAC failed to ensure a pain assessment was conducted within approximately 30 minutes after IV pain medication administration, in accordance with its policy.
Findings include:

1. The policy titled "Pain Management Plan" was reviewed on 7/23/13. It indicated "V. A. Ongoing Assessments: 2. Once pain has been identified and interventions have been initiated, the patient will be reassessed in approximately one half hour and as needed to determine effectiveness of interventions."

2. The medical record of Pt #1 was reviewed on 7/23/13. Pt #1 was admitted to the LTAC on 5/28/13 with the diagnosis Acute Respiratory Failure. On 5/29/13, there was a physician order "Morphine 3 mg IV every 3 hours as needed." Between 5/29/13 and 5/31/13, 1 out of 14 doses failed to include a pain reassessment, at all, after administration. 5 out of 13 doses failed to include a pain include a pain reassessment within 30 minutes of IV pain medication administration.

3. The medical record of Pt #2 was reviewed on 7/24/13. Pt #2 was admitted to the LTAC on 6/20/13 with the diagnosis Acute Respiratory Failure. On 7/1/13, there was a physician order "Morphine 0.5 mg IV every 4 hours needed." On 7/6/13, there was a physician order "Morphine 1 mg IV every 4 hours as needed." As of 7/24/13 at 1:00 PM, 1 out of 15 doses failed to have a pain reassessment, at all, after administration. 10 out of 14 failed to include a pain reassessment within approximately 30 minutes of IV pain medication administration.

4. The medical record of Pt #3 was reviewed on 7/24/13. Pt #3 was admitted to the LTAC on 7/2/13 with the diagnosis Acute Respiratory Failure. On 7/5/13, there was a physician order "Fentanyl 25 mcg IV every 6 hours as needed." This was discontinued on 7/11/13. Between 7/5/13 and 7/11/13, One out of one dose given failed to include a pain reassessment within 30 minutes of IV pain medication administration.

5. The medical record of Pt #7 was reviewed on 7/24/13. Pt #7 was admitted to the LTAC on 7/19/13 with the diagnosis Open Wound Site Nos- Comp. On 7/19/13, there was a physician order "Hydromorphone 1 mg IV every 8 hours as needed." As of 7/24/13 at 2:20 PM, 4 out of 4 doses failed to include a pain reassessment within approximately 30 minutes of IV pain medication administration.

6. During a staff interview, conducted with the RN Supervisor on 7/23/13 at 2:00 PM, it was verbalized that reassessment of pain after a pain medication is expected to be approximately 30 minutes after IV pain medication. It was confirmed that the medical records of Pts #1, #2, #3, #7 failed to include documentation of pain reassessment within approximately 30 minutes of IV pain medication administration.

C. Based on a review of LTAC policy, medical record review, and staff interview, it was determined in 6 of 7 (Pts #1, #2, #3, #5, #6, #7) medical records reviewed, the LTAC failed to ensure a pain reassessment was conducted within 1 hour of PO pain medication administration, in accordance with its practice.
Findings include:

1. The policy titled "Pain Management Plan" was reviewed on 7/23/13. It indicated "V. A. Ongoing Assessments: 2. Once pain has been identified and interventions have been initiated, the patient will be reassessed in approximately one half hour and as needed to determine effectiveness of interventions."

2. During a staff interview, conducted with the RN Supervisor on 7/23/13 at 2:00 PM, it was verbalized that reassessment of pain after a pain medication is expected to be approximately an hour after oral pain medication. It was confirmed that the LTAC policy says "within approximately 30 minutes" and it was verbalized "that is the expectation with IV pain medication; but with PO pain medications, we expect the pain to be reassessed within approximately one hour."

3. The medical record of Pt #1 was reviewed on 7/23/13. Pt #1 was admitted to the LTAC on 5/28/13 with the diagnosis Acute Respiratory Failure. On 5/28/13, there was a physician order "Norco 7.5/325 mg one every 6 hours as needed" and on 5/29/13, the dose was increased to 2 tablets every 6 hours as needed. Between 5/28/13 and 6/1/13, 7 out of 14 doses failed to include a pain reassessment within approximately 1 hour after PO pain medication administration.

4. The medical record of Pt #2 was reviewed on 7/24/13. Pt #2 was admitted to the LTAC on 6/20/13 with the diagnosis Acute Respiratory Failure. On 6/20/13, there was a physician order "Norco 10/325 mg one every 6 hours as needed. This was discontinued on 6/26/13. On 7/20/13, there was a physician order "Norco 10/325 mg one every 4 hours as needed." As of 7/24/13 at 1:00 PM, 1 out of 27 doses administered failed to have a pain reassessment, at all, after administration. 13 out of 26 doses administered failed to include a pain reassessment within approximately 1 hour of PO pain medication administration.

5. The medical record of Pt #3 was reviewed on 7/24/13. Pt #3 was admitted to the LTAC on 7/2/13 with the diagnosis Acute Respiratory Failure. On 7/11/13, there was a physician order "Norco 5/325 mg by mouth every 6 hours as needed." As of 7/24/13 at 2:30 PM, 3 out of 5 doses administered failed to include a pain reassessment within approximately one hour of PO pain medication administration.

6. The medical record of Pt #5 was reviewed on 7/24/13. Pt #5 was admitted to the LTAC on 6/26/13 with the diagnosis Acute Respiratory Failure. On 6/26/13, there was a physician order "Norco 5/325 mg one every 6 hours as needed." As of 7/24/13 at 2:00 PM, 4 out of 8 doses administered failed to include a pain reassessment within approximately one hour of PO pain medication administration.

7. The medical record of Pt #6 was reviewed on 7/24/13. Pt #6 was admitted to the LTAC on 7/3/13 with the diagnosis Pneumonia. On 7/4/13, there was a physician order "Norco 5/325 mg every 6 hours as needed." As of 7/24/13 at 1:30 PM, 13 out of 40 doses administered failed to include a pain reassessment within approximately one hour of PO pain medication administration.

8. The medical record of Pt #7 was reviewed on 7/24/13. Pt #7 was admitted to the LTAC on 7/19/13 with the diagnosis Open Wound Site Nos- Comp. On 7/19/13, there was a physician order "Norco 10/325 mg one every 4 hours as needed." As of 7/24/13 at 2:20 PM, 6 out of 10 doses administered failed to include a pain reassessment within approximately 1 hour of PO pain medication administration.

9. During a staff interview, conducted with the RN Supervisor on 7/24/13 at 3:00 PM, it was confirmed that the medical records of Pts #1, #2, #3, #5, #6, and #7 failed to include pain reassessments within 1 hour of PO pain medication administration.

Based on medical record review and staff interview, it was determined in 4 out of 4 (Pts #1, #2, #4, #7) medical records reviewed, the Hospital failed to ensure dietary intake was documented for each meal served.
Findings include:

1. The medical record of Pt #1 was reviewed on 7/23/13. Pt #1 was admitted to the LTAC on 5/28/13 with the diagnosis Acute Respiratory Failure. Between 5/28/13 and 6/1/13, there was no nursing documentation to indicate the amount of dietary intake for 6 out of 13 meals.

2. The medical record of Pt #2 was reviewed on 7/24/13. Pt #2 was admitted to the LTAC on 6/20/13 with the diagnosis Acute Respiratory Failure. As of 7/24/13 at 1:00 PM, there was no nursing documentation to indicate the amount of dietary intake for 7 out of 23 meals.

3. The medical record of Pt #4 was reviewed on 7/24/13. Pt #4 was admitted to the LTAC on 7/19/13 with the diagnosis Acute Respiratory Failure. As of 7/24/13 at 2:40 PM, there was no nursing documentation to indicate the amount of dietary intake for 6 out of 12 meals.

4. The medical record of Pt #7 was reviewed on 7/24/13. Pt #7 was admitted to the LTAC on 7/19/13 with the diagnosis Open Wound Site Nos- Comp. As of 7/24/13 at 2:20 PM, there was no nursing documentation to indicate the amount of dietary intake for 9 out of 14 meals.

5. During a staff interview, conducted with the RN Supervisor on 7/24/13 at 3:00 PM, it was verbalized that "I&O (Intake and Output) are documented on all patients in the LTAC." Dietary intake of each meal is expected to be documented as part of the nursing assessment of oral intake. It was confirmed that Pts #1, #2, #4, and #7 failed to have documentation of dietary intake as noted above.

Based on medical record review and staff interview, it was determined in 2 of 5 (Pts #1, #2) medical records reviewed, the Hospital failed to ensure it established and implemented a process for physician notification of missed and/or refusal of respiratory treatments.
Findings include:

1. The medical record of Pt #1 was reviewed on 7/23/13. Pt #1 was admitted to the LTAC on 5/28/13 with the diagnosis Acute Respiratory Failure. On 5/28/13, there was a physician order "Ipratropium inhalation solution 2.5 ml every 4 hours. Albuterol inhalation solution 3 ml every 4 hours as needed." Between 5/28/13 and 5/31/13, 14 out of 14 treatments were refused. There was no documentation to indicate the physician was notified until 5/31/13.

2. The medical record of Pt #2 was reviewed on 7/24/13. Pt #2 was admitted to the LTAC on 6/20/13 with the diagnosis Acute Respiratory Failure. On 6/20/13, there was an order for "Ipratropium bromide/ Albuterol sulfate inhalation solution 3 ml every 4 hours." Between 6/20/13 and 7/24/13, MAR documentation indicated 9 treatments were not given. 4 out of 9 failed to indicate why the treatment was not given. 5 out of 9 indicated "Pt sleeping". There was no documentation to indicate the physician was notified of the missed treatments.

3. A staff interview was conducted with the Director of Respiratory Therapy on 7/24/13 at 1:45 PM. "I remember Pt #1 had told our therapist that Pt#1 didn't take the nebulizers at the outlying Hospital and Pt #1 wasn't going to take them here." When asked what the process was for notifying physician(s) of patient refusal and/or of missed treatments, the following was verbalized. "Missing one treatment doesn't usually lead to notification of the physician, but if several are being refused or missed because of side effects, we notify the physician. We don't have a specific process. It's just an understood practice. My best guess with Pt #1 is that the orders came over on the Med Rec (Medication Reconciliation) from the outlying hospital. We should have gotten a DC (discontinue) order. As far as Pt #2 and the treatments being missed at 3:00 AM because of sleeping, sometimes patients tell us at the 11:00 PM treatment not to wake them up for the 3:00 AM treatment. If it becomes a pattern, like with Pt #2, we should have gotten a change in the order to address this."