HospitalInspections.org

Based on interview and record review, the facility failed to ensure that a uniformly optimal level of nursing care with regards to the assessment of patients after the administration of a pain medication was performed for 1 of 10 sampled patients (#1).

Findings:

A review of the medical record of patient #1 was performed. The patient was triaged in the Emergency Department (ED) on 3/10/17 at 8:06 PM. The triage nurse's note at that time read, "Chief complaint: right shoulder pain." Pain at this time was assessed at 10 out of 10 (10/10). Pain was assessed at 8:32 PM on 3/10/17 at 8/10. This was the last documented pain assessment in the medical record. The physician's ED Workflow sheet was signed by a Physician's Assistant (PA) on 3/10/17 at 8:40 PM, and signed by a physician at 10 PM. It read, "Medical decision making: (R) shoulder fx (fracture), pain....R (right) Shoulder CD (compact disc) reviewed. (+) fracture humeral neck non-displaced." The pain medication Hydrocodone/Acetaminophen was ordered on 3/10/17 at 8:57 PM on 3/10/17. The orders read, "hydrocodone/acetaminophen...5 MG (milligrams)/325 MG... give 1 tablet/capsule, PO (by mouth) once." This pain medication was given on 3/10/17 at 9:20 PM. The patient was discharged at 10:40 PM on 3/10/17.

A review of facility policy "Medication Administration" read, "The effects of medications including the first dose of any medication new to the patient shall be monitored for appropriateness of therapy (e.g. clinical signs and symptoms and response to medication effects) and to promptly identify and minimize the occurrence of adverse events."

A review of facility policy "Pain Management" read, "Pain reassessment: Reassess at the anticipated peak effect.... within 60 minutes... or at the defined peak effect for the specific medication/dosage form if longer than...60 minutes ...of the pain medication using the same pain scale/tool." This policy stated the following with respect to the pain scale which is used: "7 to 10 = severe pain." Since there was no evidence of a pain assessment having been performed after the administration of hydrocodone/acetaminophen, the facility was not in compliance with the above policies.

On 6/20/17 at 2:45 PM, the Risk Manager confirmed the findings.