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Based on staff interviews and facility records review, the facility failed to ensure that registered nurses evaluate the nursing care for 1 of 5 patients (Patient 4) when it failed to do the following:

1. Identify and recognize that the medication Dilaudid, ordered for pain relief, was ordered without accompanying parameters on when to administer the drug according to an established pain rating scale in which pain is evaluated by the patient as being mild, moderate or severe or with a numerical pain rating scale of 0 to 10, 10 being the most severe pain experienced to prevent unnecessary administration of the medication.

2. Reassess the efficacy and evaluate for any side effects after the administration of Dilaudid as per hospital policy.

3. Identify and recognize that the medication Norvasc, ordered to control high blood pressure, was ordered without clear instructions from the prescriber for specific parameters when to administer or withhold the medication when an assessment of the patients' blood pressure was performed in order to prevent unnecessary administration of the drug.

These deficient practices had the potential to result in affecting the physical health, safety and psychological well being of Patient 4.

Findings:

On 7/17/12, a review of Patient 4's medical record was conducted. The medical record revealed that Patient 4 was admitted to the facility emergently and underwent a surgical Laparoscopic Appendectomy on 7/2/12. Further review indicated that Patient 4 had developed post- operative complications and was readmitted to the facility on 7/9/12. Patient 4 was placed on continuous intravenous TPN (Total Parenteral Nutrition) therapy and had a naso-gastric tube (NGT) inserted due to a paralytic ileus (a post-operative complication- a non-functioning digestive tract.)

1. On 7/17/12, a review of Patient 4's Physician Orders Sheet, dated 7/9/12, and timed at 10:39 AM, revealed the following medication orders:

a. Dilaudid 0.25 milligrams IV (Intravenously) every 2 hours PRN (as necessary).

b. Pepcid 20 milligrams IV every 24 hours.

c. Ambien 5 milligrams taken by mouth every bedtime as necessary.

d. Flagyl 500 milligrams taken by mouth three times a day.

e. Norvasc 10 milligrams taken by mouth every 24 hours daily.

There was no documented evidence in the Physicians Orders Sheet, dated 7/17/12, that Patient 4's physician had ordered a clear, well-defined pain intensity rating scale, directing nursing staff with specific parameters on when to administer the drug according to an established pain rating scale in which pain is evaluated by the patient as being mild, moderate or severe or with a numerical pain rating scale of 0 to 10, 10 being the most severe pain experienced.

On 7/17/12, a review of Patient 4's Medication Administration Record (MAR), printed by the pharmacy department, from 7/9/12 through 7/17/12 was conducted. Documentation indicated Dilaudid was ordered to be given intravenous push, 0.25 milligrams every 2 hours as necessary.

There was no indication that the facility's pharmacist had identified or recognized that the Dilaudid order had any accompanying parameters instructions on when to administer the drug according to an established pain rating scale in which pain was evaluated by the patient as being mild, moderate or severe or with a numerical pain rating scale of 0 to 10, 10 being the most severe pain experienced.

On 7/17/12, a review of the facility's policy and procedure titled, "PHARMACY DEPARTMENT OPERATING POLICIES", dated 4/3/09, stipulated, " ...The hospital pharmacy department shall provide and/or identify all medications administered to patients at the facility. The pharmacy will provide a safe and efficient medication distribution system which shall include the evaluation and administration of pharmaceuticals and other chemicals ... "

There was no documented evidence that the nursing staff member signing off and noting the physicians' order, attesting that the order for Dilaudid was complete, accurate and final, and had identified or recognized the irregularity that the Dilaudid order did not have a clear, well defined pain intensity rating scale (parameters) on when to administer the drug according to the patient's perceived pain level.

On 7/17/12, a review of the facility's policy and procedure titled, "DECREASING MEDICATION ERRORS", dated 5/16/12, stipulated, " ...The facility shall be aware that errors can occur at any step on the process: prescribing, ordering or monitoring the effects of the medication. Nursing staff provides patient education on all medications ordered for and administered to the patient during their hospital admission. Training and monitoring nursing practice regarding this policy and procedure are the responsibilities of the Nurse Manager, Pharmacy, and Medication Safety Committee ... "

On 7/18/12, at approximately 9:30 AM, the Director of Quality confirmed the finding that the medication order for Dilaudid lacked clear parameters when to administer the drug for pain relief without following a defined pain intensity rating scale. He stated that the physician, pharmacist and nursing staff should have picked up on the medication irregularity order.

2. On 7/17/12, a review of Patient 4's Medication Administration Record (MAR) dated 7/9/12 through 7/17/12 was conducted. Documentation revealed on 7/14/12, at 3:13 AM, Patient 4 was administered Dilaudid 0.25 milligrams IVP for pain (no documentation of the intensity or level of pain reported). Further documentation revealed that Patient 4 was not reassessed for the efficacy or was monitored for any side effects of the medication until 5:37 AM.

In addition, documentation in Patient 4's MAR revealed that an additional dose of Dilaudid was administered at 5:39 AM for pain relief and was not reassessed for pain relief effectiveness until 10:30 AM, on 7/14/12.

On 7/17/12, a review of the facility's policy and procedure titled, " PAIN ASSESSMENT " dated 5/17/12, stipulated, " ...The patient and their families will be informed of the pain assessment tool/scale. The following pain assessment scales will be used to assess level of pain: Adjective rating scale in which pain is evaluated by the patient as mild, moderate or severe or the Numerical rating scale in which the patient should be advised that a score from 0 to 10 is used to describe the levels of pain. 10 being the most severe pain and 0 is without any pain symptoms. Pain should be assessed routinely at regular intervals. For post-operative patients every 4 hours while awake for 1 day after surgery. With each new report of pain and at suitable intervals after each analgesic intervention, 30 minutes after parental and 1 hour after oral ... "

On 7/17/12, at approximately 3:30 PM, RN 1 confirmed the finding that the nursing staff did not assess in a timely manner Patient 4's pain status after administering Dilaudid at 3:13 AM and at 5:39 AM as per facility policy.

3. On 7/17/12, a review of Patient 4's Physicians' Order Sheet dated 7/9/12 and timed at 10:39 AM was conducted. The Physicians' Order Sheet revealed an order for Norvasc 10 milligrams to be taken by mouth, administered every 24 hours.

On 7/17/12, a review of Patient 4's Medication Administration Record from 7/9/12 through 7/17/12 revealed documentation as printed by the pharmacy department that Norvasc (amlodipine) 10 milligrams was to be administered every 24 hours on a daily basis.

According to the Davis Drug Guide, dated 2011, it stated, "The patient's blood pressure and pulse should be monitored before therapy and should be contraindicated in a systolic blood pressure less than 90 mm Hg (millimeters of mercury). "

There was no indication in Patient 4's Physician's Order Sheet or from other facility sources that written instructions was ordered by the physician for monitoring the patient's blood pressure prior to administering Norvasc.

There was no documented evidence in Patient 4's Physicians' Order Sheet or from other facility sources that orders were written by the physician instructing the nursing staff to withhold the Norvasc if the systolic blood pressure was less than 90 mm Hg (millimeters of mercury).

There was no evidence that the facility's pharmacist had recognized the medication irregularity order written by the physician regarding Norvasc being withheld if the patient's systolic blood pressure was less than 90 mm Hg.

On 7/17/12, a review of the facility's policy and procedure titled, "PHARMACY DEPARTMENT OPERATING POLICIES ", dated 4/3/09, stipulated, " ...The hospital pharmacy department shall provide and/or identify all medications administered to patients at the facility. The pharmacy will provide a safe and efficient medication distribution system which shall include the evaluation and administration of pharmaceuticals and other chemicals ... "

On 7/17/12, at approximately 9:45 AM, the Director of Pharmacy confirmed the finding that Patient 4' physician should have ordered specific parameters when to withhold the medication especially if the systolic blood pressure was less than 90 mm Hg.