HospitalInspections.org

Based on interview and record review, the hospital failed to their policy and procedure titled, "Restraint Management (Mechanical, Chemical, Seclusion)," when staff did not perform and document assessment of non violent non self destructive restraints (used to prevent the patient from interfering with treatment including patient pulling out tubes, lines and drains) every two hours for one of 30 sampled patients (Pt 8).

This failure had the potential for injury and for Pt 8's needs to go unmet.

Findings:

During a concurrent interview and record review with the Clinical Navigator (CN), on 11/12/19 at 2:12 p.m., Pt 8's clinical record titled, "Order Plans" indicated, "Reassess patient every 2 hours and whenever there is a significant change in condition..." The CN validated on 11/12/19, no assessment was completed or documented at 6 a.m.

During a concurrent interview and record review with the Director of Medical Surgical Unit (DMS), on 11/13/19 at 9:25 a.m., the DMS validated restraints were to be assessed and documented every two hours per the hospital's policy. The DMS stated the importance of the assessment was to ensure Pt 8 was not having discomfort or any musculoskeletal (muscles, ligaments and tendons, and bones) problems at the site of the applied restraints. The DMS stated the nurse was responsible for reassessing the patient every two hours and the expectation of staff was to assess and document the findings in the medical record. The DMS stated the potential harm was injury to the site of the restraints.

A review of the hospital policy and procedure titled, "Restraint Management (Mechanical, Chemical, Seclusion)" dated 6/12/19, indicated, " ...E. Restraint Considerations- Non- Violent/ Non Self Destructive...1. These types of restraint order are used to protect the physical safety of non violent or no self destructive patients...3. Assessment and monitoring will be conducted at minimum, every 2 hours..."

Based on interview and record review, the hospital failed to administer medication as prescribed for one of 30 sampled patients (Pt 3).

This failure had the potential to result in improper medication administration.

Findings:

During a concurrent interview and record review with the Clinical Navigator (CN), on 11/12/19 at 2:12 p.m., Pt 8's Medication Administration Summary (MAR) indicated, "PRN (medications given as needed), acetaminophen 650 mg (milligram-form of measurement) ...Fever..." The CN validated the medication was prescribed for fever. The CN validated on 11/8/19 at 2:10 p.m., the prescribed medication was administered for pain, and not a fever.

During a concurrent interview and record review with the Director of Medical Surgical Unit (DMS), on 11/13/19 at 9:20 a.m., the DMS validated Pt 8's acetaminophen order was prescribed for fever, but administered by nursing staff for pain. The DMS stated the medication was not given for the prescribed indication. The DMS stated her expectation of staff was to call the physician and obtain an order for pain. The DMS stated medications were prescribed by the physician and the order should have been followed. The DMS stated it was not within the nurse's scope of practice (range of roles, functions, responsibilities, and activities which registered nurses are educated and authorized to perform) to not follow the physician's order.

A review of the hospital policy and procedure titled, "Medication Administration" dated 6/26/18, indicated, "...1. Medication shall be administered to patients after being prescribed by a physician or practitioner functioning within their scope of practice and licensure..."

Based on interview and record review, the hospital failed to document a reassessment in the electronic medical record (EMR) when a pain reassessment (an evaluation of the reported pain and the factors that make the pain better or worse, as well as the response to treatment of pain using numeric pain scale of 1 to 10, 1 being the least pain and 10 being the worst pain) was not completed for one of 30 sampled patients (Pt 8).

This failure had the potential for Pt 8 to not receive adequate pain relief.

Findings:

During a concurrent interview and record review with the Director of Medical Surgical Unit (DMS), on 11/13/19 at 9:20 a.m., Pt 8's Medication Administration Summary (MAR) indicated, "Acetaminophen- hydrocodone 325 mg (milligram-unit of measurement)- 5 mg...administered 11/12/19...5:18 a.m...pain intensity: 5...pain location...Uterus (the organ in the lower body of a woman )..." The DMS was unable to find documentation of a pain reassessment completed 60 minutes after administration of the pain medication. The DMS stated her expectation was for a reassessment to be completed 60 minutes after pain medication administration and the reassessment should have been documented at 6:18 a.m. The DMS stated reassessment of pain was important to evaluate if the intervention was effective for Pt 8, and if changes need to be made to the plan of care. The DMS stated the hospital did not have a policy and procedure with specific guidelines for nursing staff to follow regarding pain reassessment and documentation. The DMS stated nursing staff follow Lippincott (evidence-based procedure guidance) to established performance criteria for the nursing staff.

A review of the document titled, "Lippincott Procedures - Pain Assessment" dated 12/14/18, indicated, "...Each facility should have defined criteria to screen, assess and reassess a patient's pain. These criteria should be consistent with the patient's age, condition and ability to understand...Reassessment of pain at designated intervals according to the type of pain intervention used...is needed to evaluate progress towards pain management goals...Reassess and respond to the patient's pain by evaluating the response to treatment and progress toward pain management goals...Document initial assessment finding and any reassessment findings, as indicated. Document the date and time of the assessment, the assessment tool used, the pain or comfort indicators present. Describe the patient's behavior, positron of comfort and activity level. Evaluate and document changes since previous measures. Include interventions performed, the patient's response to them. Progress toward pain management goals..."