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LAKELAND REGIONAL MEDICAL CENTER
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on record review, staff interview and review of policy and procedures it was determined the Registered Nurse (RN) failed to supervise and evaluate the patient's pain level following a pain management intervention for one (#21) of thirty patient's sampled. This does not ensure the patient's pain goal has been achieved.
Findings include:
Patient #21's was admitted for surgery on 5/10/2012. Review of the physician orders dated 5/12/2012 revealed an order for Percocet 5/325 mg (milligrams) 1-2 tablets every 6 hours as needed for pain.
Review of nursing documentation revealed on 5/13/2012 at 12:58 a.m. the patient reported pain. The documentation revealed no numeric rating using a scale from 1 to 10, with 10 meaning the worst pain. Review of the MAR (Medication Administration Record) revealed at 12:58 a.m. Percocet was administered for the reported pain. Review of the nursing documentation revealed the patient's pain was reassessed at 6:36 a.m.
Review of the facility's policy, "Acute Pain: Assessment and Symptom Management", effective 10/2008, indicated pain scores are documented. After any pain management intervention, the pain score is reassessed at an appropriate interval for the given intervention.
Interview with the patient's RN and the manager of the unit on 5/14/2012 at 12:15 p.m. confirmed that pain was reassessed within an hour of the pain management intervention to determine the effectiveness. The interview confirmed the patient's pain level was not reassessed until approximately five and a half hours following the pain intervention.
ADMINISTRATION OF DRUGS
Tag No.: A0405
Based on record review and staff interview it was determined the nursing staff failed to administer medications according to the physicians orders for one (#20) of thirty patients sampled. This does not ensure therapeutic medication therapy.
Findings include:
Patient #20's physician order dated 5/11/2012 instructed for Humalog insulin 3 units SQ (subcutaneous) three times a day before meals. Review of the MAR (Medication Administration Record) for 5/12/2012 revealed at 12:46 p.m. the patient was administered Humalog insulin 1 unit SQ. At 5:05 p.m. the patient was not administered Humalog insulin.
Interview with the manager of the B8 unit confirmed the Humalog insulin was not administered according to physician orders.