HospitalInspections.org

Based on hospital policy review, document review, medical record review and interview, the hospital failed to ensure patients rights were protected when they failed to assess patients for pain, failed to administer pain medications and failed to reassess patients's response per facility policy, after the administration of pain medications for 3 of 3 (Patient #1, #2, and #3) sampled patients. The hospital also failed to ensure patients rights were protected when Patient #1 had patient controlled analgesia (PCA) initiated and there was no reassessment to ensure the pump was delivering the medication as expected.
The findings included:

1. Review of the hospital's "Pain Assessment and Management" policy effective 5/26/2021 revealed, "...Scope: This policy applies to clinical staff who assess and manage pain. (Exceptions: patients who have been converted to comfort care/hospice care. Refer to policy 8720-0062)...Pain is assessed at regular intervals and treated utilizing a pain assessment scale, ordered medications and other appropriate measures...Screen and/or assess all patients for the presence of pain, inpatients and outpatients...assessment for each new report of pain includes...Location of pain..Duration of Pain...Pain score...Pain Assessment tools include: Numeric Pain Intensity Scale 0 to 10. This scale is a number line from 0 to 10. 0 is no pain at all and 10 is the worst pain...Critical Care Pain Observation Tool (CPOT)...Indicator...Body Movements...Slow, cautious movements touching or rubbing the pain site, seeking attention through movements...attempting to sit up, moving limbs/thrashing, not following commands, striking at staff...Vocalization...Sighing, moaning, Crying out, sobbing...Rating Scale: 0 = [equals] No pain 1-2 = Mild pain 3-5 = Moderate pain 6-8 = Severe pain...Non Verbal Pain Scale-FLACC Scale (Face, Legs, Activity, Cry, Consolable) The FLACC is a behavior assessment scale for use in non-verbal patients unable to provide reports of pain...Rating Scale: 0 None 1-2 Mild 3-6 Moderate 7-10 Severe...Legs...Uneasy, restless, tense...Activity...squirming, shifting back and forth, tense...Cry...Moans or whimpers; occasional complaint...Pain interventions will be individualized for each patient based on the assessment...Initiate treatment of pain...If pain relief measures are ineffective, alternate measures are to be taken and documented in the patient's record...Documentation elements include...Initial screening and/or assessment of pain...Response to analgesic (score) in the eMAR within one hour...Comprehensive assessment of all new reports of pain...Pain reassessment - location, intensity (score) every shift..."

2. Review of the hospital's "PCA Pumps" [number 8720-0062] policy effective 9/20/2020 revealed, "... Scope: This policy applies to [named hospital]...The purpose of the policy is to provide guidelines for the safe infusion of narcotics via a patient-controlled analgesia (PCA) pump...A. All patients are assessed before the ordering of the PCA mode of pain medication delivery. Assessment is done regarding the patient's cognitive status and their ability to comprehend the use of the PCA. If the patient is not capable of utilizing the PCA method of pain management appropriately and effectively then the physician, nurse, and or pharmacist collaborate to determine other options of delivery of the pain medication but administration via a PCA pump must be by the patient. EXCEPTION: terminally ill patient receiving a continuous infusion. B. Either two RNs [Registered Nurse] and or one Pharmacist are responsible for the set-up and programming, including any changes to the PCA Pump. Initial programming verification is to be documented in the MAR [Medication Administration Record]...D. An RN is responsible for the management of the PCA infusion pump, including programming and troubleshooting. The RN assigned to the patient is responsible for evaluating pain control. Based on assessment or order changes, the RN must make the changes with another RN or Pharmacist. E. A physician or RN must deliver initial bolus dose and monitor patient's response. Document bolus given and response in Nurses Notes and/or PCA flow sheet. F. Vital signs (LOC [level of consciousness] with BP [blood pressure] RR [respiratory rate], HR [heart rate]) are to be taken when pump is initiated and with any changes; q [every] 30 mm [minutes] X [times] 2, then q 2 hours x2, then q 4 hours while on PCA. G. Assess and document patient level of pain (0-10)...Procedure..Obtain/Verify Physician order for PCA...Set up pump as outlined in manufacturer's guidelines and per physician orders...Verify pump setting each shift with the oncoming and off going Nurse...Assess and document patient's response..."

3. Review of the hospital's "Hospice Care" policy effective 6/1/2021 revealed, "...Scope: This policy applies to [named hospital]...and its off-campus departments...The purpose of this policy is to provide and comfort the patients, family and/or significant other during the final stages of life...Consideration will be given to the following...Effective pain management/comfort...Offer PRN pain medications and evaluate effectiveness. Communicate effectiveness to physician for any necessary medication adjustments..."

4. Review of the hospital's "Medication Administration and EMAR Usage" policy effective 7/24/2019 revealed, "..."Witness or Nurse Witness" is a visual observation procedure in which two clinicians (nurse or pharmacist) separately check each component of prescribing, dispensing, and verifying a medication before administering or wasting the medication...Controlled Medications..."PRN" [as needed] medications, including narcotics, are to be removed upon patient request and should be given immediately upon removal. Documentation should be completed at the time the medication is given to the patient. "PRN" medications administered will have the parameters for use, i.e. [such as], patient's blood sugar, blood pressure documented at the time of administration...The "PRN" Response form will be completed to verify the patient's response to the medication given. This is to be completed within an hour of administration..."

5. Review of the hospital's "DMC Patient Controlled Analgesia Part 1: PCA Pump Basics" Learnshare training module revealed, "...PCA...Assessment...Obtain a full set of baseline VS [Vital Signs], Pain Scale...before infusion begins...When initiated: 15 minutes after starting PCA, Q 2 hours x 2 times, Q 4 hours and PRN...If pain is not well controlled after 2 hours reassess...Common PCA Pitfalls...PCA pump malfunction..."

6. Review of the "Alaris System User Manual Alaris Pump Module, Model 8100 Alaris Syringe Module, Model 8110" revealed, "...Warnings...The Pump and Syringe modules are designed to stop fluid flow under alarm conditions. Periodic patient monitoring must be performed to ensure that the infusion is proceeding as expected...Alarms, Errors, Messages...Syringe Module Alarm...Occlusion...Meaning...Increased back pressure sensed while infusing. Infusion stops on affected module..."

7. Patient #1 was an 83 year old male who was transported to the facility's Emergency Department after falling at home. The patient complained of back pain upon arrival. The patient was diagnosed with Dehydration, Covid-19 Pneumonia, and Hyperkalemia. (Dehydration is excessive loss of body water. Pneumonia is a severe inflammation of the lungs in which the alveoli (tiny air sacs) are filled with fluid. Hyperkalemia is a serum plasma potassium level above the upper limits of normal. ) Patient #1 remained hospitalized and was treated and initially showed some improvement; however, the patient later became more confused and refused to eat or participate with therapy services. Patient #1 began experiencing increased pain and lethargy and the decision was made to place the patient on Comfort Care Only and Do Not Resuscitate. Orders were written for intravenous morphine for severe pain as well as Lorazepam (Ativan) for anxiety and comfort. (Morphine is a narcotic analgesic used to treat pain. Lorazepam is a sedative agent used to relieve anxiety.) Patient #1 was not reassessed for medication effectiveness within an hour after administration of pain medication repeatedly. On 1/16/2023, the nurse caring for Patient #1 failed to assess the patient for pain, failed to administer pain medication, administered Zofran in an effort to calm the patient down, and failed to monitor and reassess Patient #1 after initiation of the PCA pump. (Zofran is prescribed and approved to treat nausea and vomiting.) Patient #1 went without pain relieving medication for a total of 15 hours and 52 minutes.
The hospital failed to ensure patient's rights were protected when the PCA pump was initiated but the PCA pump was not running to deliver medication to Patient #1, leaving him without pain medications.

8. Patient #2 was a 44 year old male who was admitted to the hospital with a Post Operative Infection of his left lower leg and Cellulitis. (Cellulitis is a bacterial skin infection in which the affected skin is swollen and inflamed and is typically painful and warm to the touch.) Patient #2 had pain medications ordered to be given as needed. The patient was in the hospital for a total of 3 days and was only assessed for pain once during his entire hospital stay. The hospital also failed to protect patient rights when it failed to document pain assessments and reassessments to ensure pain relieving interventions provided relief.

9. Patient #3 was a 71 year old male who was admitted to the hospital with Leukocytosis, Anemia, Osteomyelitis of the left toe, Chronic Hypomagnesemia, and Open wound of the right great toe. (Leukocytosis is an increase in the number of white cells in the blood, especially during an infection. Anemia is a condition in which the body does not have enough healthy red blood cells. Red blood cells provide oxygen to body tissues. Osteomyelitis is an inflammation of the bone caused by an infection, which may spread to the bone marrow and tissues near the bone. Osteomyelitis can cause severe pain in the infected bone. Hypomagnesemia is an electrolyte disturbance caused be a low serum magnesium level in the blood.) Patient #3 had pain medications ordered to be given as needed. The patient was not assessed at least once a shift and was not reassessed within one hour after pain medications were administered repeatedly. The hospital also failed to protect patient rights when it failed to document pain assessments and reassessments to ensure pain relieving interventions provided relief.

Refer to A 0130.

Based on hospital policy review, document review, medical record review, and interview, the hospital failed to ensure patients' rights for 3 of 3 (Patient #1, #2, and #3) sampled patients when they failed to manage and assess the patients' pain levels on an ongoing basis and failed to reassess patients after the administration of pain medication in a timely manner. The facility also failed to ensure patients' rights to be free of pain when a patient controlled analgesic (PCA) pump was initiated but was found not working.

The findings included:

1. Review of the hospital's "Pain Assessment and Management" policy effective 5/26/2021 revealed, "...Scope: This policy applies to clinical staff who assess and manage pain. (Exceptions: patients who have been converted to comfort care/hospice care. Refer to policy 8720-0062)...Pain is assessed at regular intervals and treated utilizing a pain assessment scale, ordered medications and other appropriate measures...Screen and/or assess all patients for the presence of pain, inpatients and outpatients...assessment for each new report of pain includes...Location of pain..Duration of Pain...Pain score...Pain Assessment tools include: Numeric Pain Intensity Scale 0 to 10. This scale is a number line from 0 to 10. 0 is no pain at all and 10 is the worst pain...Critical Care Pain Observation Tool (CPOT)...Indicator...Body Movements...Slow, cautious movements touching or rubbing the pain site, seeking attention through movements...attempting to sit up, moving limbs/thrashing, not following commands, striking at staff...Vocalization...Sighing, moaning, Crying out, sobbing...Rating Scale: 0 = [equals] No pain 1-2 = Mild pain 3-5 = Moderate pain 6-8 = Severe pain...Non Verbal Pain Scale-FLACC Scale (Face, Legs, Activity, Cry, Consolable) The FLACC is a behavior assessment scale for use in non-verbal patients unable to provide reports of pain...Rating Scale: 0 None 1-2 Mild 3-6 Moderate 7-10 Severe...Legs...Uneasy, restless, tense...Activity...squirming, shifting back and forth, tense...Cry...Moans or whimpers; occasional complaint...Pain interventions will be individualized for each patient based on the assessment...Initiate treatment of pain...If pain relief measures are ineffective, alternate measures are to be taken and documented in the patient's record...Documentation elements include...Initial screening and/or assessment of pain...Response to analgesic (score) in the eMAR within one hour...Comprehensive assessment of all new reports of pain...Pain reassessment - location, intensity (score) every shift..."

2. Review of the hospital's "PCA Pumps" [number 8720-0062] policy effective 9/20/2020 revealed, "... Scope: This policy applies to [named hospital]...The purpose of the policy is to provide guidelines for the safe infusion of narcotics via a patient-controlled analgesia (PCA) pump...A. All patients are assessed before the ordering of the PCA mode of pain medication delivery. Assessment is done regarding the patient's cognitive status and their ability to comprehend the use of the PCA. If the patient is not capable of utilizing the PCA method of pain management appropriately and effectively then the physician, nurse, and or pharmacist collaborate to determine other options of delivery of the pain medication but administration via a PCA pump must be by the patient. EXCEPTION: terminally ill patient receiving a continuous infusion. B. Either two RNs [Registered Nurse] and or one Pharmacist are responsible for the set-up and programming, including any changes to the PCA Pump. Initial programming verification is to be documented in the MAR [Medication Administration Record]...D. An RN is responsible for the management of the PCA infusion pump, including programming and troubleshooting. The RN assigned to the patient is responsible for evaluating pain control. Based on assessment or order changes, the RN must make the changes with another RN or Pharmacist. E. A physician or RN must deliver initial bolus dose and monitor patient's response. Document bolus given and response in Nurses Notes and/or PCA flow sheet. F. Vital signs (LOC [level of consciousness] with BP [blood pressure] RR [respiratory rate], HR [heart rate]) are to be taken when pump is initiated and with any changes; q [every] 30 mm [minutes] X [times] 2, then q 2 hours x2, then q 4 hours while on PCA. G. Assess and document patient level of pain (0-10)...Procedure..Obtain/Verify Physician order for PCA...Set up pump as outlined in manufacturer's guidelines and per physician orders...Verify pump setting each shift with the oncoming and off going Nurse...Assess and document patient's response..."

3. Review of the hospital's "Hospice Care" policy effective 6/1/2021 revealed, "...Scope: This policy applies to [named hospital]...and its off-campus departments...The purpose of this policy is to provide and comfort the patients, family and/or significant other during the final stages of life...Consideration will be given to the following...Effective pain management/comfort...Offer PRN [as needed] pain medications and evaluate effectiveness. Communicate effectiveness to physician for any necessary medication adjustments..."

4. Review of the hospital's "Medication Administration and EMAR Usage" policy effective 7/24/2019 revealed, "..."Witness or Nurse Witness" is a visual observation procedure in which two clinicians (nurse or pharmacist) separately check each component of prescribing, dispensing, and verifying a medication before administering or wasting the medication...Controlled Medications..."PRN" medications, including narcotics, are to be removed upon patient request and should be given immediately upon removal. Documentation should be completed at the time the medication is given to the patient. "PRN" medications administered will have the parameters for use, i.e. [such as], patient's blood sugar, blood pressure documented at the time of administration...The "PRN" Response form will be completed to verify the patient's response to the medication given. This is to be completed within an hour of administration..."

5. Review of the hospital's "DMC Patient Controlled Analgesia Part 1: PCA Pump Basics" Learnshare training module revealed, "...PCA...Assessment...Obtain a full set of baseline VS [Vital Signs], Pain Scale...before infusion begins...When initiated: 15 minutes after starting PCA, Q 2 hours x 2 times, Q 4 hours and PRN...If pain is not well controlled after 2 hours reassess...Common PCA Pitfalls...PCA pump malfunction..."

6. Review of the "Alaris System User Manual Alaris Pump Module, Model 8100 Alaris Syringe Module, Model 8110" revealed, "...Warnings...The Pump and Syringe modules are designed to stop fluid flow under alarm conditions. Periodic patient monitoring must be performed to ensure that the infusion is proceeding as expected...Alarms, Errors, Messages...Syringe Module Alarm...Occlusion...Meaning...Increased back pressure sensed while infusing. Infusion stops on affected module..."

7. Medical record review revealed Patient #1 was an 83 year old male who presented to the hospital's Emergency Department (ED) via Emergency Medical Services (EMS) on 1/2/2023 after suffering a fall in his home and lying in the floor for approximately 12 hours until he was discovered by the Complainant. Review of the ED provider's note dated 1/2/2023 revealed "...Per pt [patient], he reports falling and being on the floor for the past 12 hours, but denies remembering how he fell...In the ED, he reports having back pain with movement, but denies any other pain...confirms using O2 [oxygen] at home..." The note further revealed Patient #1 underwent diagnostic testing and was ultimately admitted to the hospital under the care of Physician #1 with diagnoses which included Fall at home, Covid - 19, Pneumonia and Weakness. (Pneumonia is a severe inflammation of the lungs in which the alveoli (tiny air sacs) are filled with fluid.) The patient had past medical history significant for Coronary Artery Disease, Hypertension, Obesity, and Venous Stasis Dermatitis. (Coronary Artery Disease is a disease in which there is a narrowing or blockage of the coronary arteries, the blood vessels that carry blood and oxygen to the heart. Hypertension or high blood pressure is a condition in which the blood vessels have persistently raised pressure. Obesity is a state or condition of being very overweight. Venous Stasis Dermatitis is inflammation, typically of the skin of the lower legs, caused by chronic edema or swelling.)

Review of an order written by Physician #1 on 1/2/2023 at 6:18 PM revealed the patient was admitted to the hospital for inpatient services.

Review of an order written by Physician #1 on 1/2/2023 at 6:54 PM revealed the patient could have Zofran 4 milligrams (mg) intravenously (IV) q 6 hr prn for Nausea and/or Vomiting. (Zofran is a medication used to treat nausea and vomiting.)

Review of an order written by Physician #1 on 1/2/2023 at 6:54 PM revealed the patient could have Tylenol 650 mg by mouth every 6 hours as needed for mild pain.

Review of the Admission History and Physical completed by Physician #1 on 1/3/2023 at 5:47 PM revealed Patient #1 was found on floor by the Complainant after lying there for 12 hours following a fall. The patient was complaining of back pain. The patient was admitted with Covid -19 infection/pneumonia with dehydration and hyperkalemia.

Patient #1 remained hospitalized where he was treated for the pneumonia, dehydration, and hyperkalemia. The patient's condition improved and preparations were being made for his discharge.

Review of an order written by Physician #1 on 1/9/2023 at 12:27 PM, revealed to Discharge Patient and send to Inpatient Rehab (rehabilitation). Patient #1 was denied admission to inpatient rehab.

Review of a Progress Note written by Physician #1 on 1/10/2023 at 4:51 PM revealed Patient #1 was examined by the physician. The patient was noted to be in his bed and was comfortable. Patient #1 was considered to be stable medically. Acute rehabilitation refused to accept the patient. Skilled nursing facility placement was pending due to the patient being refused by inpatient rehabilitation.

Review of a Progress Note written by Physician #1 on 1/11/2023 at 2:43 PM revealed Patient #1 was still medically stable for discharge and was awaiting placement in a skilled nursing facility.

Review of an order written by Physician #1 on 1/11/2023 at 2:49 PM, revealed Discharge Patient to Skilled Nursing Facility.

Review of a Progress Note written by Physician #1 on 1/12/2023 at 4:02 PM revealed Patient #1 was seen and examined. He was awaiting skilled nursing facility placement authorization.

Review of a Progress Note written by Physician #1 on 1/13/2023 at 6:37 PM revealed Patient #1 was seen and examined. The family reported patient is more confused today. The patient is alert, seems appropriate, but weak and restless, anxious. Awaiting placement authorization.

Review of an order written by Physician #1 on 1/14/2023 at 2:46 PM, revealed ketorolac (Toradol) 15 mg IV Push, Once. (Toradol is a non-steroidal anti-inflammatory drug used to treat pain.)

Review of the eMAR dated 1/14/2023 at 3:00 PM revealed Patient #1 was given Toradol 15 mg IV Push. There was no documentation Patient #1 was assessed for pain before or after the medication was administered. The facility failed to ensure patients' rights to be free of pain when the patient was not assessed before or after the medication was administered.

Review of a Progress Note written by Physician #1 on 1/14/2023 at 5:16 PM revealed Patient #1 was seen and examined. Patient was refusing to eat and drink. The family stated patient was in pain. The patient was in bed and looked anxious and uncomfortable. Depressed; not wanting to eat or drink or work with therapy. He has told the nurse to leave him alone and let him die. The physician progress note documented to continue current management and supportive care. The physician discussed this with the family. The patient continued to be awaiting placement arrangement authorization. Documentation revealed the patient prognosis is unknown at this time.

Review of an order written by Physician #1 on 1/14/2023 at 5:49 PM revealed morphine 1 mg IV Push, every 3 hours as needed for severe pain. (Morphine is a narcotic used to treat moderate to severe pain.)

Review of the eMAR dated 1/14/2023 at 6:32 PM revealed Patient #1 was given morphine 1 mg IV Push for Severe pain.

Review of the eMAR dated 1/14/2023 at 7:32 PM revealed morphine was not effective.

Review of the nursing flowsheets Pain Assessment portion dated 1/14/2023 at 8:00 PM revealed Patient #1 had no actual or suspected pain.

Review of the nursing flowsheets Pain Assessment portion dated 1/15/2023 at 12:00 AM revealed Patient #1 had no actual or suspected pain.

Review of the eMAR dated 1/15/2023 at 12:35 AM revealed Patient #1 was given morphine 1 mg IV Push for severe pain.

Patient #1 was not reassessed for pain and/or medication effectiveness until 3:21 AM, a total of 2 hours and 46 minutes later, at which time, the eMAR revealed morphine was administered for agitation; Medication was effective. The facility failed to ensure patients' rights to be free of pain when the patient was not reassessed for pain until 2 hours and 46 minutes after the medication was administered.

Review of the eMAR dated 1/15/2023 at 3:39 AM revealed Patient #1 was given morphine 1 mg IV Push for severe pain.

Patient #1 was not reassessed for pain and/or medication effectiveness until 5:51 AM, a total of 2 hours and 12 minutes later, at which time the eMAR revealed morphine was given for anxiety but it was not effective so the provider was notified. There was no documentation any additional pain management interventions were implemented. The facility failed to ensure patients' rights to be free of pain when the patient was not reassessed for pain until 2 hours and 12 minutes after the medication was administered.

Review of the eMAR dated 1/15/2023 at 8:20 AM revealed Patient #1 was given morphine 1 mg IV Push for Severe pain.

Review of the eMAR dated 1/15/2023 at 9:20 AM revealed .morphine was given for severe pain. The patient's symptoms improved and the medication was effective.

Review of the eMAR dated 1/15/2023 at 11:36 AM revealed Patient #1 was given morphine 1 mg IV Push for severe pain.

Review of an order written by Physician #1 on 1/15/2023 at 12:08 PM revealed "... Do Not Resuscitate [DNR]..."

Review of an order written by Physician #1 on 1/15/2023 at 12:09 PM revealed "...Comfort Measures Only."

Review of the eMAR dated 1/15/2023 at 12:36 PM revealed morphine administered for pain. Documentation revealed the medication was effective and symptoms improved.

Review of the eMAR dated 1/15/2023 at 3:26 PM revealed Patient #1 was given morphine 1 mg IV Push for severe pain.

Review of an order written by Physician #1 on 1/15/2023 at 3:42 PM revealed Lorazepam 1 mg IV Push, every 2 hours as needed for comfort.

Review of a Progress Note written by Physician #1 on 1/15/2023 at 3:44 PM revealed Patient #1 was seen and examined, lethargic and tachypneic. (Tachypneic means breathing abnormally fast.) The patient's family was at bedside. The patient had been made a DNR and comfort care only patient as requested by the family. "...He is lethargic but restless and will possibly transition to GIP [General Inpatient]..."

Review of the eMAR dated 1/15/2023 at 4:10 PM revealed Patient #1 was given Lorazepam 1 mg IV Push for Comfort.

Review of the eMAR dated 1/15/2023 at 4:26 PM revealed morphine was given previously with symptoms improved.

Review of the eMAR dated 1/15/2023 at 5:10 PM revealed Lorazepam was given previously with symptoms improved.

Review of the eMAR dated 1/15/2023 at 6:29 PM revealed Patient #1 was given morphine 1 mg IV Push for severe pain.

Patient #1 was not reassessed for pain and/or medication effectiveness until 8:00 PM, a total of 1 hour and 31 minutes later, at which time the nursing flowsheets Pain Assessment portion revealed Patient #1 had a pain level score of "0" indicating "No pain."

Review of the eMAR dated 1/15/2023 at 11:32 PM revealed Patient #1 was given Lorazepam 1 mg IV Push for Comfort.

Review of the nursing flowsheets Pain portion 1:23 AM on 1/16/2023 revealed Patient #1 had a pain level score of "8" indicating severe pain.

Review of the eMAR dated 1/16/2023 at 1:23 AM revealed Patient #1 was given morphine 1 mg IV push for Severe pain.

Review of the eMAR dated 1/16/2023 at 2:23 AM revealed morphine was previously given with symptoms improved. Documentation revealed the morphine was given for Agitation and the medication was effective.

Review of the eMAR dated 1/16/2023 at 3:05 AM revealed Lorazepam was given with the medication effective. Documentation revealed the medication was given for anxiety and the patient's symptoms had improved.

Review of the nursing flowsheets, Neurological portion dated 1/16/2023 at 8:00 AM revealed Patient #1 was noted to be lethargic, anxious, and agitated. There was no pain assessment documented.

Patient#1 did not receive interventions to address his anxiety and agitation until 9:59 AM, a total of 1 hour and 59 minutes later at which time the eMAR revealed Patient #1 was given Lorazepam 1 mg IV Push for Comfort. There was no pain assessment documented. The facility failed to ensure patients' rights to be free of pain/comfortable when the patient did not receive interventions to address anxiety and agitation until 1 hour and 59 minutes after the medication was administered.

Review of the eMAR dated 1/16/2023 at 10:15 AM revealed Lorazepam was given for nausea and the medication was effective. Nurse #1 documented the Lorazepam, a medication used to treat anxiety, was given for "Nausea."

Review of the eMAR dated 1/16/2023 at 11:13 AM revealed Patient #1 was given Zofran 4 mg IV Push for nausea and/or vomiting.

Review of the eMAR dated 1/16/2023 at 12:00 PM revealed Patient #1 was given Lorazepam 1 mg IV Push for Comfort.

Review of the eMAR dated 1/16/2023 at 12:13 PM revealed Zofran was given for Nausea and the patient's symptoms were improved.

Review of the eMAR dated 1/16/2023 at 12:20 PM revealed Lorazepam was given for agitation, anxiety with symptoms improved.

Nurse#1 documented the patient was given Lorazepam for agitation, anxiety." There was no documentation Patient #1 was assessed for pain. The facility failed to ensure patients' rights when the patient was not assessed for pain before the medication was administered.

Review of the Discharge Summary written by Physician #1 on 1/16/2023 at 1:45 PM revealed, Patient #1 "...was initially admitted with COVID-19 infection. Pneumonia. Dehydration. Encephalopathy...Fall...Plan initially was for placement in acute rehab [rehabilitation] however patient was denied. Later Plan B was for skilled nursing facility admission...patient started to decline with decreased p.o. [per oral (by mouth)] intake. Refused to take his medicine. Participate with therapy. Back on IV fluid. This was discussed with the family. And later family decided to make the patient DO NOT RESUSCITATE. Comfort care only. This was on 1/15/2023. Today on 1/16/2023 patient lethargic. Restless at times. Family at bedside. They asked to proceed with hospice consult and transition patient..."

Review of an order written by Physician #1 on 1/16/2023 at 1:45 PM revealed morphine 1 mg/mL IV PCA Bolus Dose, Initial (mg) 1...Basal Rate 1 milligrams per hour (mg/hr).

Review of an order written by Physician #1 on 1/16/2023 at 1:45 PM revealed Hospice Evaluate and treat.

Review of the eMAR dated 1/16/2023 at 3:09 PM revealed "...morphine 1mg/ml PCA 30 mg Begin Bag...30 mL, 1mL/hr IV...Perform: [RN #1] & Witness: [RN 2]..."

There was no documentation Patient #1's level of consciousness, pain level and/or vital signs were assessed before the PCA pump was initiated at 3:09 PM. There was no documentation Patient #1 was reassessed by Nurse #1 or any other hospital staff member until after the Hospice Nurse arrived and began completing the patient's initial assessment. The facility failed to ensure patients' rights to be free of pain when the patient was not reassessed after the PCA pump was initiated.

Review of Patient #1's "Initial Patient Assessment" obtained from Hospice Agency #1 revealed the assessment was completed onsite in the hospital on 1/16/2023 from 5:30 PM through 8:00 PM. The assessment revealed Patient #1's initial vital signs were blood pressure of 99/77, pulse was elevated at 120 beats per minute, respiratory rate was 20 and his Oxygen saturation rate was low at 89%. Further review revealed the reasons for inpatient hospice services included, "...Pain...Respiratory Distress...Mental Status Changes..." The pain assessment portion revealed Patient #1's pain severity score was documented as "5" indicating the patient was experiencing moderate pain. The nursing narrative documentation revealed, Patient #1 was "...moaning and restlessly moving legs and arms, unable to voice discomfort. Breathing labored...Ordered patient morphine and Ativan for comfort...Patient admitted..."

Continued review of Patient #1's hospital record revealed there was no documentation Patient #1 was assessed for pain by any hospital staff member from 2:23 AM on 1/16/2023 until 7:38 PM. a total of 17 hours and 15 minutes, when Nurse #3 assumed care of the patient; and there was no documentation Patient #1 was given morphine for pain from 1:23 AM on 1/16/2023 until 3:09 PM when the PCA pump was initiated, a total of 13 hours and 14 minutes. The facility failed to ensure patients' rights to be free of pain when the patient was not assessed for pain for 17 hours and 15 minutes; and was not reassessed after the PCA pump was initiaed for a total of 13 hours and 14 minutes.

Review of the eMAR dated 1/16/2023 at 7:38 PM revealed Patient #1 was given morphine 1 mg IV Push for severe pain and Lorazepam 1 mg IV Push for Comfort.

Patient #1 was not reassessed for pain and/or medication effectiveness until 1/17/2023 at 2:04 AM, a total of 6 hours and 26 minutes later, at which time the eMAR revealed morphine administered for Pain with symptoms improved; Lorazepam was given for anxiety and medication was effective, patient's symptoms improved.

Review of the nursing flowsheets Pain portion dated 1/17/2023 at 2:08 AM revealed Patient #1 had "No actual or suspected pain."

Review of the eMAR dated 1/17/2023 at 2:43 AM revealed Patient #1 was given Lorazepam 1 mg IV Push for comfort.

Review of the eMAR dated 1/17/2023 at 2:48 AM revealed Lorazepam was administered for anxiety and medication response symptoms improved.

Review of the eMAR dated 1/17/2023 at 3:59 AM revealed Patient #1 was given morphine 1 mg IV Push for Severe pain.

Patient #1 was not reassessed for pain and/or medication effectiveness until 6:26 AM, a total of 2 hours and 27 minutes later, at which time the eMAR Continuous Infusions portion revealed morphine was administered for Pain with symptoms improved. The facility failed to ensure patients' rights to be free of pain when the patient was not reassessed until 2 hours and 27 minutes after the medication was administered.

Patient #1 was transitioned to inpatient hospice care on 1/17/2023 at 12:27 PM.

8. In a telephone interview on 3/8/2023 at 3:33 PM, the Complainant, Patient #1's daughter, stated when she arrived at the hospital on the morning of 1/16/2023, she went to the nurses station to inform staff she had arrived for the day and asked which nurse would be caring for the patient that day. The complainant stated Nurse#1 stated she was the patient's nurse and told the Complainant, she had just come back from medical leave and she "was foggy." The Complainant continued and stated when she went in to see her father (Patient#1) he appeared to be in pain; he was "moaning." The Complainant stated she went back to the nurses station and asked [named Nurse #1] when was the last time the patient had any medication for pain and the nurse told her it would be another "45 minutes" before any more medication could be given. The Complainant continued and stated, "after 45 minutes she [Nurse#1] came back and put something in his arm [IV site]. I'm thinking it was morphine. After an hour and a half, he was no better. I went back to the nurse [Nurse #1] and said whatever you gave him wasn't working. She [Nurse #1] told me she gave him Zofran, not morphine or Ativan because she thought that would settle him down. She [Nurse #1] still didn't give him morphine; she gave him something else that started with an L [Lorazepam] to settle him down..."

The Complainant stated Physician #1 saw Patient #1 between 12:00 PM and 1:30 PM on 1/16/2023. The Complainant said when Physician #1 evaluated the patient, he stated "he's [Patient #1] miserable; so unsettled." The Complainant continued and stated Physician #1 told her he thought hospice would be best for the patient "so we [hospital] can start a constant Morphine drip...He said I'm writing the order now..." The Complainant stated she knew it would take a little bit of time for the pharmacy to prepare the medication and send it up.

The Complainant stated two nurses (Nurse #1 and #2) brought in the IV pole, pump, 2 IV bags and a clear cylinder. "They [the nurses] put the cylinder in a clear box and [Nurse #1] started pushing buttons and the other nurse left before [Nurse #1] finished setting up the machine." The Complainant stated Patient #1 didn't get any relief after the machine was set up. The Complainant continued and stated Nurse #1 "...appeared as if she didn't quite know how to use the machine [PCA pump]..." The Complainant then stated when the Hospice Nurse arrived at approximately 5:30 PM, the nurse looked at Patient #1 who was "moaning and groaning", then looked at the PCA pump and stated, "This machine is not on!" The hospice nurse then went directly to the nurses station and got Nurse #1. When Nurse #1 arrived in the patient's room, she told them she had to get a key to work the machine, then left the room. The Complainant then stated, "I never saw [Nurse #1] again that day." The Complainant stated the Hospice Nurse went back to the nurses station around shift change and had the evening shift nurse [Nurse #3] come into the room and showed him that the pump was not working. Nurse #3 went and got a key and came back in the patient's room and got the pump working. The Complainant stated, "Only 10 minutes and my father [Patient #1] was at peace; that's all it took!"

The Complainant stated she reported all of her concerns to the hospital's Director of Clinical Quality Improvement and Chief Nursing Officer. The Complainant continued and stated the Director of Clinical Quality Improvement was "in tears when she heard how her father [Patient #1] had suffered" The Complainant continued and stated she knew she made a scene and was inappropriate with some of her language, but she was trying her best to make sure no other patients had to suffer like her father (Patient#1) did. The Complainant then stated, "I can't get what I witnessed my father go through out of mind! I keep replaying it over and over because he [Patient #1] suffered so much!"

9. In a telephone interview on 3/15/2023 at 8:20 AM, the Hospice Nurse verified she completed the initial evaluation on Patient #1. The Hospice Nurse stated she went into the patient's room on 1/16/2023 at approximately 5:30 PM and introduced herself to the patient, his daughter (Complainant) and a male family member. The Hospice Nurse stated she looked at the patient, then noticed the PCA pump was not on so she asked the Complainant "Are they waiting on me to start the pump? The daughter [Complainant] stated, 'No, they already started the pump because he [Patient #1] was in a significant amount of pain'." The Hospice Nurse stated "I went to find the nurse [RN #1] but she was no where to be found. They [staff at the nurses station] said they would let her [RN #1] know I was there. I went back to the patient's room. I did his initial vital signs and assessed his pain level. He [Patient #1] seemed to be in quite a bit of pain. He was lethargic and everything I did he seemed to be in pain and he moaned and groaned." The Hospice Nurse then stated she and the Complainant went to the lobby area where she informed her about hospice services and they completed the admission paperwork. The Hospice Nurse stated after they completed the admission paperwork, she noticed Nurse #1 had returned to the floor and she told the nurse (Nurse #1) she could go ahead start the PCA pump. The Hospice Nurse continued and stated, Nurse #1 told her "It's [the PCA pump] already been started; I [Nurse #1] set it up myself with another nurse." The Hospice Nurse informed Nurse #1 the pump was not working, so Nurse #1 went into Patient #1's room, then came back out and said the pump was on. The Hospice Nurse stated the pump was still not on, so "the second time I told her the pump was not working, she [Nurse#1] said she was looking for a key. I don't know where she went or what she did; she just disappeared." The Hospice Nurse stated she was at the nurses station writing the orders for the patient so "I decided to talk to the oncoming nurse [Nurse #3] because it was shift change..." The Hospice Nurse stated she informed the Nurse #3 the patient's PCA pump was off. The Hospice Nurse then stated, "He [Nurse #3] looked at it [PCA pump] and verified the pump was not on. The patient's daughter [Complainant] was very upset. She went and got the Charge Nurse and went off on her. He'd [Patient #1] been in pain." The Hospice Nurse stated Nurse #3 immediately set up the pump and together, they repositioned the patient. The Hospice Nurse stated the patient was comfortable in less than 30 minutes. The Hospice Nurse was asked if it appeared any medicine had been given from the PCA pump when she first noticed it was off. The Hospice Nurse stated, "What I looked at was for the green light; it was not on. It did not appear that any medication had been given, but I cannot say for sure."

10. In an interview on 3/20/2023 at 10:20 AM, Nurse #2 was asked how she would determine if a patient was in pain. The nurse stated, "moaning, groaning or stating they were in pain." The nurse was asked how often patients should be assessed for pain and where it should be documented. Nurse #2 stated, "Every 2 hours with rounding; it's supposed to be documented under the pain assessments every 2 hours." Nurse #2 verified she was present in Patient #1's room when Nurse #1 set up the PCA pump. The nurse stated she remained in the room until the loading dose was delivered. Nurse #2 was asked if she noticed if Patient #1 responded to the medication. The nurse stated, "Not that I recall." Nurse #2 was asked if she had any other interactions with Patient #1 to see if he responded to the medication. Nurse #2 stated, " I went in to get the dirty linen bag; I didn't stay long enough to interact with the patient." Nurse #2 was asked how she would chose between Lorazepam and morphine to administer to a patient when both medications were ordered. The nurse stated, "Lorazepam is given for anxiety, agitation, and some comfort measures...give morphine for moaning and groaning or if it looks like he's [patient] in pain."

In an interview on 3/20/2023 at 10:36 AM Nurse #1 was asked how she would determine if a patient was in pain. The nurse stated, the patient might be "rubbing their legs, state it grimacing; if they are non verbal sometimes I go by the heart rate, crying out..." The nurse was asked how often patients should be assessed for pain and where it should be documented. Nurse #1 stated, "Every 4 hours; if I give medicine, within an hour to see if it's been effective. We document pain assessments under the nurses notes." Nurse #1 was asked if she could recall caring for Patient #1 on 1/16/2023. The nurse confirmed she could and stated "He [Patient #1] was a DNR, toward the latter part of my shift; he was made Hospice and given medication for transition from earthly bound to heavenly bound." Nurse #1 was asked if Patient #1 ever complained of nausea while she was providing care to him. Nurse#1 stated, "No, he was kind of a non-verbal patient; he mainly just moaned." Nurse #1 was asked how she would choose between Lorazepam and morphine to administer to a patient when both medications were ordered. Nurse #1 stated, she would gi

Based on hospital policy review, document review, medical record review and interview, the hospital failed to ensure Nursing Services provided care and services to meet patients needs when they failed to assess patients for pain, failed to administer pain medications and failed to reassess patients's response per facility policy, after the administration of pain medications for 3 of 3 (Patient #1, #2, and #3) sampled patients; Nursing Services failed to ensure hospital policies to prevent central line blood stream infections were followed for 1 of 3 (Patient #3) sampled patients.

The hospital's failure to perform pain assessments before and after the administration of pain medications resulted in Patient #3, an 83 year old male who had been receiving morphine intravenously for pain, going without a pain assessment or pain medication for a total of 11 hours and 23 minutes when an ordered morphine Patient Controlled Analgesia (PCA) pump was initiated. The hospital's failure to ensure the PCA pump policy was followed resulted in Patient #3 going an additional 4 hours and 29 minutes without pain relief.

The findings included:

1. Review of the hospital's "Pain Assessment and Management" policy effective 5/26/2021 revealed, "...Scope: This policy applies to clinical staff who assess and manage pain. (Exceptions: patients who have been converted to comfort care/hospice care. Refer to policy 8720-0062)...Pain is assessed at regular intervals and treated utilizing a pain assessment scale, ordered medications and other appropriate measures...Screen and/or assess all patients for the presence of pain, inpatients and outpatients...assessment for each new report of pain includes...Location of pain..Duration of Pain...Pain score...Pain interventions will be individualized for each patient based on the assessment...Initiate treatment of pain...If pain relief measures are ineffective, alternate measures are to be taken and documented in the patient's record...Documentation elements include...Initial screening and/or assessment of pain...Response to analgesic (score) in the eMAR [electronic medical record] within one hour...Comprehensive assessment of all new reports of pain...Pain reassessment - location, intensity (score) every shift..."

2. Review of the hospital's "PCA Pumps" [number 8720-0062] policy effective 9/20/2020 revealed, "... Scope: This policy applies to [named hospital]...The purpose of the policy is to provide guidelines for the safe infusion of narcotics via a patient-controlled analgesia (PCA) pump...A. All patients are assessed before the ordering of the PCA mode of pain medication delivery. Assessment is done regarding the patient's cognitive status and their ability to comprehend the use of the PCA. If the patient is not capable of utilizing the PCA method of pain management appropriately and effectively then the physician, nurse, and or pharmacist collaborate to determine other options of delivery of the pain medication but administration via a PCA pump must be by the patient. EXCEPTION: terminally ill patient receiving a continuous infusion...D. An RN [Registered Nurse] is responsible for the management of the PCA infusion pump, including programming and troubleshooting. The RN assigned to the patient is responsible for evaluating pain control...E. A physician or RN must deliver initial bolus dose and monitor patient's response. Document bolus given and response in Nurses Notes and/or PCA flow sheet. F. Vital signs (LOC [level of consciousness] with BP [blood pressure] RR [respiratory rate], HR [heart rate]) are to be taken when pump is initiated and with any changes; q [every] 30 mm [minutes] X [times] 2, then q 2 hours x2, then q 4 hours while on PCA. G. Assess and document patient level of pain (0-10)...Procedure..Obtain/Verify Physician order for PCA...Set up pump as outlined in manufacturer's guidelines and per physician orders..Assess and document patient's response..."

3. Review of the hospital's "Hospice Care" policy effective 6/1/2021 revealed, "...Scope: This policy applies to [named hospital]...and its off-campus departments...The purpose of this policy is to provide and comfort the patients, family and/or significant other during the final stages of life...Consideration will be given to the following...Effective pain management/comfort...Offer PRN [as needed] pain medications and evaluate effectiveness. Communicate effectiveness to physician for any necessary medication adjustments..."

4. Review of the hospital's "Medication Administration and EMAR Usage" policy effective 7/24/2019 revealed, "...PRN" medications administered will have the parameters for use, i.e. [such as], patient's blood sugar, blood pressure documented at the time of administration...The "PRN" Response form will be completed to verify the patient's response to the medication given. This is to be completed within an hour of administration..."

5. Review of the hospital's "DMC Patient Controlled Analgesia Part 1: PCA Pump Basics" Learnshare training module revealed, "...PCA...Assessment...Obtain a full set of baseline VS [Vital Signs], Pain Scale...before infusion begins...When initiated: 15 minutes after starting PCA, Q 2 hours x 2 times, Q 4 hours and PRN...If pain is not well controlled after 2 hours reassess...Common PCA Pitfalls...PCA pump malfunction..."

6. Review of the "Alaris System User Manual Alaris Pump Module, Model 8100 Alaris Syringe Module, Model 8110" revealed, "...Warnings...The Pump and Syringe modules are designed to stop fluid flow under alarm conditions. Periodic patient monitoring must be performed to ensure that the infusion is proceeding as expected..."

7. Patient #1 was an 83 year old male who was transported to the facility's Emergency Department after falling at home. The patient complained of back pain upon arrival. The patient was diagnosed with Dehydration, Covid-19 Pneumonia, and Hyperkalemia. (Dehydration is excessive loss of body water. Pneumonia is a severe inflammation of the lungs in which the alveoli (tiny air sacs) are filled with fluid. Hyperkalemia is a serum plasma potassium level above the upper limits of normal. ) Patient #1 remained hospitalized and was treated and initially showed some improvement; however, the patient later became more confused and refused to eat or participate with therapy services. Patient #1 began experiencing increased pain and lethargy and the decision was made to place the patient on Comfort Care Only and Do Not Resuscitate. Orders were written for intravenous morphine for severe pain as well as Lorazepam (Ativan) for anxiety and comfort. (Morphine is a narcotic analgesic used to treat pain. Lorazepam is a sedative agent used to relieve anxiety.) Patient #1 was not reassessed for medication effectiveness within an hour after administration of pain medication repeatedly. On 1/16/2023, the nurse caring for Patient #1 failed to assess the patient for pain, failed to administer pain medication, administered Zofran in an effort to calm the patient down, and failed to monitor and reassess Patient #1 after initiation of the PCA pump. (Zofran is prescribed and approved to treat nausea and vomiting.) Patient #1 went without pain relieving medication for a total of 15 hours and 52 minutes.

8. Patient #2 was a 44 year old male who was admitted to the hospital with a Post Operative Infection of his left lower leg and Cellulitis. (Cellulitis is a bacterial skin infection in which the affected skin is swollen and inflamed and is typically painful and warm to the touch.) Patient #2 had pain medications ordered to be given as needed. The patient was in the hospital for a total of 3 days and was only assessed for pain once during his entire hospital stay.

9. Patient #3 was a 71 year old male who was admitted to the hospital with Leukocytosis, Anemia, Osteomyelitis of the left toe, Chronic Hypomagnesemia, and Open wound of the right great toe. (Leukocytosis is an increase in the number of white cells in the blood, especially during an infection. Anemia is a condition in which the body does not have enough healthy red blood cells. Red blood cells provide oxygen to body tissues. Osteomyelitis is an inflammation of the bone caused by an infection, which may spread to the bone marrow and tissues near the bone. Osteomyelitis can cause sever pain in the infected bone. Hypomagnesemia is an electrolyte disturbance caused be a low serum magnesium level in the blood.) Patient #3 had pain medications ordered to be given as needed. The patient was not assessed at least once a shift and was not reassessed within one hour after pain medications were administered repeatedly.

10. Review of the hospital's "Clinical Guidelines: Venous Access Device: Prevention, Insertion and Maintenance" policy effective 2/28/2020 revealed, "...The policy establishes guidelines for the insertion and management of vascular access devices (VADs) and outlines evidence-based clinical practice guidelines that [named hospital] follows to reduce the incidence of Central Line Associate Bloodstream Infections (CLABSI) and any other complications related to vascular access devices...Dressing Change...Change transparent semipermeable membrane (TSM) dressing at least every 7 days and immediately if the dressing integrity becomes loose, visibly soiled, or if moisture or blood are present under the dressing...VAD Present on Administration [Admission]...Verify tip placement...Remove dressing to assess insertion site...Follow previous instructions for maintenance, dressing, and blood draws..."

12. Patient #3 was admitted to the hospital on 1/24/2023 with diagnoses which included Leukocytosis, Anemia, Left Toe Osteomyelitis, Chronic Hypomagnesemia, and Open wound of the right great toe. The patient had a totally implanted VAD (Portacath) present on admission. Patient #3 was discharged on 2/1/2023. There was no documentation Patient #3' Portacath dressing was changed the entire 8 days of his hospital stay.

Refer to A 0395.

Based on hospital policy review, document review, medical record review, and interview, the hospital failed to ensure nursing services provided adequate oversight and supervision to ensure patient's needs were met when they failed to manage and assess patient's pain levels on an ongoing basis and failed to reassess patients after the administration of pain medication in a timely manner for 3 of 3 (Patient #1, #2, and #3) sampled patients; the facility failed to ensure measures to prevent potential central line blood stream infections were followed for 1 of 3 (Patient #3) sampled patients reviewed.

The findings included:

1. Review of the hospital's "Pain Assessment and Management" policy effective 5/26/2021 revealed, "...Scope: This policy applies to clinical staff who assess and manage pain. (Exceptions: patients who have been converted to comfort care/hospice care. Refer to policy 8720-0062)...Pain is assessed at regular intervals and treated utilizing a pain assessment scale, ordered medications and other appropriate measures...Screen and/or assess all patients for the presence of pain, inpatients and outpatients...assessment for each new report of pain includes...Location of pain..Duration of Pain...Pain score...Pain Assessment tools include: Numeric Pain Intensity Scale 0 to 10. This scale is a number line from 0 to 10. 0 is no pain at all and 10 is the worst pain...Critical Care Pain Observation Tool (CPOT)...Indicator...Body Movements...Slow, cautious movements touching or rubbing the pain site, seeking attention through movements...attempting to sit up, moving limbs/thrashing, not following commands, striking at staff...Vocalization...Sighing, moaning, Crying out, sobbing...Rating Scale: 0 = [equals] No pain 1-2 = Mild pain 3-5 = Moderate pain 6-8 = Severe pain...Non Verbal Pain Scale-FLACC Scale (Face, Legs, Activity, Cry, Consolable) The FLACC is a behavior assessment scale for use in non-verbal patients unable to provide reports of pain...Rating Scale: 0 None 1-2 Mild 3-6 Moderate 7-10 Severe...Legs...Uneasy, restless, tense...Activity...squirming, shifting back and forth, tense...Cry...Moans or whimpers; occasional complaint...Pain interventions will be individualized for each patient based on the assessment...Initiate treatment of pain...If pain relief measures are ineffective, alternate measures are to be taken and documented in the patient's record...Documentation elements include...Initial screening and/or assessment of pain...Response to analgesic (score) in the eMAR within one hour...Comprehensive assessment of all new reports of pain...Pain reassessment - location, intensity (score) every shift..."

2. Review of the hospital's "PCA Pumps" [number 8720-0062] policy effective 9/20/2020 revealed, "... Scope: This policy applies to [named hospital]...The purpose of the policy is to provide guidelines for the safe infusion of narcotics via a patient-controlled analgesia (PCA) pump...A. All patients are assessed before the ordering of the PCA mode of pain medication delivery. Assessment is done regarding the patient's cognitive status and their ability to comprehend the use of the PCA. If the patient is not capable of utilizing the PCA method of pain management appropriately and effectively then the physician, nurse, and or pharmacist collaborate to determine other options of delivery of the pain medication but administration via a PCA pump must be by the patient. EXCEPTION: terminally ill patient receiving a continuous infusion. B. Either two RNs [Registered Nurse] and or one Pharmacist are responsible for the set-up and programming, including any changes to the PCA Pump. Initial programming verification is to be documented in the MAR [Medication Administration Record]...D. An RN is responsible for the management of the PCA infusion pump, including programming and troubleshooting. The RN assigned to the patient is responsible for evaluating pain control. Based on assessment or order changes, the RN must make the changes with another RN or Pharmacist. E. A physician or RN must deliver initial bolus dose and monitor patient's response. Document bolus given and response in Nurses Notes and/or PCA flow sheet. F. Vital signs (LOC [level of consciousness] with BP [blood pressure] RR [respiratory rate], HR [heart rate]) are to be taken when pump is initiated and with any changes; q [every] 30 mm [minutes] X [times] 2, then q 2 hours x2, then q 4 hours while on PCA. G. Assess and document patient level of pain (0-10)...Procedure..Obtain/Verify Physician order for PCA...Set up pump as outlined in manufacturer's guidelines and per physician orders...Verify pump setting each shift with the oncoming and off going Nurse...Assess and document patient's response..."

3. Review of the hospital's "Hospice Care" policy effective 6/1/2021 revealed, "...Scope: This policy applies to [named hospital]...and its off-campus departments...The purpose of this policy is to provide and comfort the patients, family and/or significant other during the final stages of life...Consideration will be given to the following...Effective pain management/comfort...Offer PRN pain medications and evaluate effectiveness. Communicate effectiveness to physician for any necessary medication adjustments..."

4. Review of the hospital's "Medication Administration and EMAR Usage" policy effective 7/24/2019 revealed, "..."Witness or Nurse Witness" is a visual observation procedure in which two clinicians (nurse or pharmacist) separately check each component of prescribing, dispensing, and verifying a medication before administering or wasting the medication...Controlled Medications..."PRN" [as needed] medications, including narcotics, are to be removed upon patient request and should be given immediately upon removal. Documentation should be completed at the time the medication is given to the patient. "PRN" medications administered will have the parameters for use, i.e. [such as], patient's blood sugar, blood pressure documented at the time of administration...The "PRN" Response form will be completed to verify the patient's response to the medication given. This is to be completed within an hour of administration..."

5. Review of the hospital's "DMC Patient Controlled Analgesia Part 1: PCA Pump Basics" Learnshare training module revealed, "...PCA...Assessment...Obtain a full set of baseline VS [Vital Signs], Pain Scale...before infusion begins...When initiated: 15 minutes after starting PCA, Q 2 hours x 2 times, Q 4 hours and PRN...If pain is not well controlled after 2 hours reassess...Common PCA Pitfalls...PCA pump malfunction..."

6. Review of the "Alaris System User Manual Alaris Pump Module, Model 8100 Alaris Syringe Module, Model 8110" revealed, "...Warnings...The Pump and Syringe modules are designed to stop fluid flow under alarm conditions. Periodic patient monitoring must be performed to ensure that the infusion is proceeding as expected...Alarms, Errors, Messages...Syringe Module Alarm...Occlusion...Meaning...Increased back pressure sensed while infusing. Infusion stops on affected module..."

7. Medical record review revealed Patient #1 was an 83 year old male who presented to the hospital's Emergency Department (ED) via Emergency Medical Services (EMS) on 1/2/2023 after suffering a fall in his home and lying in the floor for approximately 12 hours until he was discovered by the Complainant. Review of the ED provider's note dated 1/2/2023 revealed "...Per pt [patient], he reports falling and being on the floor for the past 12 hours, but denies remembering how he fell...In the ED, he reports having back pain with movement, but denies any other pain...confirms using O2 [oxygen] at home..." The note further revealed Patient #1 underwent diagnostic testing and was ultimately admitted to the hospital under the care of Physician #1 with diagnoses which included Fall at home, Covid - 19, Pneumonia and Weakness. (Pneumonia is a severe inflammation of the lungs in which the alveoli (tiny air sacs) are filled with fluid.) The patient had past medical history significant for Coronary Artery Disease, Hypertension, Obesity, and Venous Stasis Dermatitis. (Coronary Artery Disease is a disease in which there is a narrowing or blockage of the coronary arteries, the blood vessels that carry blood and oxygen tot he heart. Hypertension or high blood pressure is a condition in which the blood vessels have persistently raised pressure. Obesity is a state or condition of being very overweight. Venous Stasis Dermatitis is inflammation, typically of the skin of the lower legs, caused by chronic edema or swelling.)

Review of an order written by Physician #1 on 1/2/2023 at 6:18 PM revealed "...Admit to Inpatient..."

Review of an order written by Physician #1 on 1/2/2023 at 6:54 PM revealed "...Zofran...4 mg [milligrams] = [equal] 2 mL [milliliters], Injection, IV [intravenously] Push, Q [every] 6 hr [hours], PRN [as needed] For: Nausea and/or Vomiting..." (Zofran is a medication used to treat nausea and vomiting.)

Review of an order written by Physician #1 on 1/2/2023 at 6:54 PM revealed "...Tylenol...650 mg = 2 tab [tablet]...Oral [by mouth], Q6hr, PRN, For: Pain Mild..."

Review of the Admission History and Physical completed by Physician #1 on 1/3/2023 at 5:47 PM revealed Patient #1 "...C/O [complained of] back pain following fall at home...found on floor by [Complainant] after lying there for 12 hours...complaining of back pain...admitted with Covid -19 infection/pneumonia with dehydration and hyperkalemia..."

Patient #1 remained hospitalized where he was treated for the pneumonia, dehydration, and hyperkalemia. The patient's condition improved and preparations were being made for his discharge.

Review of an order written by Physician #1 on 1/9/2023 at 12:27 PM, revealed "...Discharge Patient...Once Scheduled, Inpatient Rehab [rehabilitation]..." Note, Patient #1 was denied admission to inpatient rehab.

Review of a Progress Note written by Physician #1 on 1/10/2023 at 4:51 PM revealed Patient #1 "...was seen and examined. He is in bed comfortable...Medically stable...He has been refused acute rehab. Skilled nursing facility placement is pending..."

Review of a Progress Note written by Physician #1 on 1/11/2023 at 2:43 PM revealed Patient #1 "...was seen and examined. He is doing fairly well...Family at bedside...Comfortable in bed...He is medically stable awaiting placement..."

Review of an order written by Physician #1 on 1/11/2023 at 2:49 PM, revealed "...Discharge Patient...Once Scheduled, Skilled Nursing Facility..."

Review of a Progress Note written by Physician #1 on 1/12/2023 at 4:02 PM revealed Patient #1 "...was seen and examined. He is in bed comfortable. Family at bedside...Awaiting skilled nursing facility placement authorization..."

Review of a Progress Note written by Physician #1 on 1/13/2023 at 6:37 PM revealed Patient #1 "...was seen and examined. Family reported patient is more confused today...alert seems appropriate but weak and restless...anxiety...Awaiting placement authorization..."

Review of an order written by Physician #1 on 1/14/2023 at 2:46 PM, revealed "...ketorolac (Toradol)...15 mg = 1 mL, Injection, IV Push, Once..." (Toradol is a non-steroidal anti-inflammatory drug used to treat pain.)

Review of the eMAR dated 1/14/2023 at 3:00 PM revealed Patient #1 was given "...Toradol...15 mg 1 mL...IV Push..." There was no documentation Patient #1 was assessed for pain before or after the medication was administered.

Review of a Progress Note written by Physician #1 on 1/14/2023 at 5:16 PM revealed Patient #1 "...was seen and examined. Family at bedside. Patient is refusing to eat. To drink. Work with therapy. Family stated patient is in pain...In bed looks anxious and uncomfortable...Depressed. Not wanting to eat or drink or work with therapy. He has told the nurse to leave him alone and let him die...Continue current management and supportive care. Discussed with family. Patient continued to be awaiting placement arrangement authorization. Prognosis is unknown at this time..."

Review of an order written by Physician #1 on 1/14/2023 at 5:49 PM revealed "...morphine...1 mg = 0.5 mL, Injection, IV Push, Q 3hr, PRN, For: Pain Severe..." (Morphine is a narcotic used to treat moderate to severe pain.)

Review of the eMAR dated 1/14/2023 at 6:32 PM revealed Patient #1 was given "...morphine...1 mg...IV Push...Reason for Medication...Pain Severe..."

Review of the eMAR dated 1/14/2023 at 7:32 PM revealed "...morphine...Medication Effective: No; Medication Administration Reason: Agitation: Medication Response: Continue to observe for symptoms..."

Review of the nursing flowsheets Pain Assessment portion dated 1/14/2023 at 8:00 PM revealed Patient #1 had "...No actual or suspected pain."

Review of the nursing flowsheets Pain Assessment portion dated 1/15/2023 at 12:00 AM revealed Patient #1 had "...No actual or suspected pain."

Review of the eMAR dated 1/15/2023 at 12:35 AM revealed Patient #1 was given "...morphine...1 mg IV Push...Reason for Medication...Pain Severe..."

Patient #1 was not reassessed for pain and/or medication effectiveness until 3:21 AM, a total of 2 hours and 46 minutes later, at which time, the eMAR revealed "...morphine...Medication Administration Reason: Agitation; Medication Effective: Yes; Medication Response: Symptoms improved..."

Review of the eMAR dated 1/15/2023 at 3:39 AM revealed Patient #1 was given "...morphine...1 mg...IV Push...Reason for Medication...Pain Severe..."

Patient #1 was not reassessed for pain and/or medication effectiveness until 5:51 AM, a total of 2 hours and 12 minutes later, at which time the eMAR revealed "...morphine...Medication Administration Reason: Anxiety; Medication Response: Provider notified; Medication Effective: No..." There was no documentation any additional pain management interventions were implemented.

Review of the eMAR dated 1/15/2023 at 8:20 AM revealed Patient #1 was given "...morphine...1 mg...IV Push...Reason for Medication...Pain Severe..."

Review of the eMAR dated 1/15/2023 at 9:20 AM revealed, "...morphine...Medication Response: Symptoms improved, Continued to observed for symptoms: Medication Effective: Yes; Medication Administration Reason: Pain..."

Review of the eMAR dated 1/15/2023 at 11:36 AM revealed Patient #1 was given "...morphine...1 mg...IV Push...Reason for Medication...Pain Severe..."

Review of an order written by Physician #1 on 1/15/2023 at 12:08 PM revealed "...Do Not Resuscitate [DNR]..."

Review of an order written by Physician #1 on 1/15/2023 at 12:09 PM revealed "...Comfort Measures Only."

Review of the eMAR dated 1/15/2023 at 12:36 PM revealed, "...morphine...Medication Administration Reason: Pain; Medication Effective: Yes; Medication Response: Symptoms improved, Continue to observe for symptoms..."

Review of the eMAR dated 1/15/2023 at 3:26 PM revealed Patient #1 was given "...morphine...1 mg...IV Push...Reason for Medication...Pain Severe..."

Review of an order written by Physician #1 on 1/15/2023 at 3:42 PM revealed "...Lorazepam...1 mg = 0.5 mL, Injection, IV Push, Q2hr, PRN, For: Comfort..."

Review of a Progress Note written by Physician #1 on 1/15/2023 at 3:44 PM revealed Patient #1 "...was seen and examined. He is lethargic. Tachypneic. [Tachypneic means breathing abnormally fast.] His family is at bedside. As per his family request. Patient has been made DNR and comfort care only...Lethargic...Restless...possible transition to GIP [General Inpatient]..."

Review of the eMAR dated 1/15/2023 at 4:10 PM revealed Patient #1 was given "...Lorazepam...1 mg...IV Push...16:10...Reason for Medication...Comfort..."

Review of the eMAR dated 1/15/2023 at 4:26 PM revealed, "...morphine...Medication Response: Symptoms improved, Continue to observe for symptoms; Medication Administration Reason: Pain..."

Review of the eMAR dated 1/15/2023 at 5:10 PM revealed, "...Lorazepam...Medication Response: Symptoms improved, Continue to observe for symptoms; Medication Administration Reason: Pain..."

Review of the eMAR dated 1/15/2023 at 6:29 PM revealed Patient #1 was given "...morphine...1 mg...IV Push...18:29...Reason for Medication...Pain Severe..."

Patient #1 was not reassessed for pain and/or medication effectiveness until 8:00 PM, a total of 1 hour and 31 minutes later, at which time the nursing flowsheets Pain Assessment portion revealed Patient #1 had a pain level score of "0" indicating "No pain."

Review of the eMAR dated 1/15/2023 at 11:32 PM revealed Patient #1 was given "...Lorazepam...1 mg...IV Push...Reason for Medication...Comfort..."

Review of the nursing flowsheets Pain portion 1:23 AM on 1/16/2023 revealed Patient #1 had a pain level score of "8" indicating severe pain.

Review of the eMAR dated 1/16/2023 at 1:23 AM revealed Patient #1 was given "...morphine...1 mg...IV Push...Reason for Medication...Pain Severe..."

Review of the eMAR dated 1/16/2023 at 2:23 AM revealed, "...morphine...Medication Response: Symptoms improved; Medication Administration Reason: Agitation; Medication Effective: Yes..."

Review of the eMAR dated 1/16/2023 at 3:05 AM revealed, "...Lorazepam...Medication Effective: Yes; Medication Administration Reason: Anxiety; Medication Response: Symptoms improved..."

Review of the nursing flowsheets, Neurological portion dated 1/16/2023 at 8:00 AM revealed Patient #1 was noted to be lethargic, anxious, and agitated. There was no pain assessment documented.

Patient#1 did not receive interventions to address his anxiety and agitation until 9:59 AM, a total of 1 hour and 59 minutes later at which time the eMAR revealed Patient #1 was given "...Lorazepam...1 mg...IV Push...Reason for Medication...Comfort..." There was no pain assessment documented.

Review of the eMAR dated 1/16/2023 at 10:15 AM revealed, "...Lorazepam...Medication Effective: Yes; Medication Response: Continue to observe for symptoms; Medication Administration Reason: Nausea..."
Nurse #1 documented the Lorazepam, a medication used to treat anxiety, was given for "Nausea."

Review of the eMAR dated 1/16/2023 at 11:13 AM revealed Patient #1 was given "...Zofran...4 mg...IV Push...Reason for Medication...Nausea and/or Vomiting..."

Review of the eMAR dated 1/16/2023 at 12:00 PM revealed Patient #1 was given "...Lorazepam...1 mg...IV Push...Reason for Medication...Comfort..."

Review of the eMAR dated 1/16/2023 at 12:13 PM revealed, "...Zofran...Medication Administration Reason: Nausea; Medication Response: Symptoms improved; Medication Effective: Yes..."

Review of the eMAR dated 1/16/2023 at 12:20 PM revealed, "...Lorazepam...Medication Response: Symptoms improved; Medication Effective: Yes; Medication Administration Reason: Agitation, Anxiety..."

Nurse#1 documented the patient was given Lorazepam for "Agitation, Anxiety." There was no documentation Patient #1 was assessed for pain.

Review of the Discharge Summary written by Physician #1 on 1/16/2023 at 1:45 PM revealed, Patient #1 "...was initially admitted with COVID-19 infection. Pneumonia. Dehydration. Encephalopathy...Fall...Plan initially was for placement in acute rehab [rehabilitation] however patient was denied. Later Plan B was for skilled nursing facility admission...patient started to decline with decreased p.o. [per oral (by mouth)] intake. Refused to take his medicine. Participate with therapy. Back on IV fluid. This was discussed with the family. And later family decided to make the patient DO NOT RESUSCITATE. Comfort care only. This was on 1/15/2023. Today on 1/16/2023 patient lethargic. Restless at times. Family at bedside. They asked to proceed with hospice consult and transition patient..."

Review of an order written by Physician #1 on 1/16/2023 at 1:45 PM revealed "...morphine 1mg/mL...IV PCA...Bolus Dose, Initial (mg) 1...Basal Rate (mg/hr) [milligrams per hour] 1..."

Review of an order written by Physician #1 on 1/16/2023 at 1:45 PM revealed, "...Hospice Eval [evaluate] & [and] Treat..."

Review of the eMAR dated 1/16/2023 at 3:09 PM revealed "...morphine 1mg/ml PCA 30 mg...Begin Bag...30 mL, 1mL/hr IV...Perform: [RN #1]...Witness: [RN 2]..."

There was no documentation Patient #1's level of consciousness, pain level and/or vital signs were assessed before the PCA pump was initiated at 3:09 PM. There was no documentation Patient #1 was reassessed by Nurse #1 or any other hospital staff member until after the Hospice Nurse arrived and began completing the patient's initial assessment .

Review of Patient #1's "Initial Patient Assessment" obtained from Hospice Agency #1 revealed the assessment was completed onsite in the hospital on 1/16/2023 from 5:30 PM through 8:00 PM. The assessment revealed Patient #1's initial vital signs were blood pressure of 99/77, pulse was elevated at 120 beats per minute, respiratory rate was 20 and his Oxygen saturation rate was low at 89%. Further review revealed the reasons for inpatient hospice services included, "...Pain...Respiratory Distress...Mental Status Changes..." The pain assessment portion revealed Patient #1's pain severity score was documented as "5" indicating the patient was experiencing moderate pain. The nursing narrative documentation revealed, Patient #1 was "...moaning and restlessly moving legs and arms, unable to voice discomfort. Breathing labored...Ordered patient morphine and Ativan for comfort...Patient admitted..."

Continued review of Patient #1's hospital record revealed there was no documentation Patient #1 was assessed for pain by any hospital staff member from 2:23 AM on 1/16/2023 until 7:38 PM. a total of 17 hours and 15 minutes, when Nurse #3 assumed care of the patient; and there was no documentation Patient #1 was given morphine for pain from 1:23 AM on 1/16/2023 until 3:09 PM when the PCA pump was initiated, a total of 13 hours and 14 minutes.

Review of the eMAR dated 1/16/2023 at 7:38 PM revealed Patient #1 was given "...morphine...1 mg...IV Push...Reason for Medication...Pain Severe..." and "...Lorazepam...1 mg...IV Push...Reason for Medication...Comfort..."

Patient #1 was not reassessed for pain and/or medication effectiveness until 1/17/2023 at 2:04 AM, a total of 6 hours and 26 minutes later, at which time the eMAR revealed, "...morphine...Medication Administration Reason: Pain; Medication Response: Symptoms Improved..."Medication Effective: Yes...Lorazepam...Medication Administration Reason: Anxiety; Medication Effective: Yes; Medication Response: Symptoms Improved..."

Review of the nursing flowsheets Pain portion dated 1/17/2023 at 02:08 (2:08 AM) revealed Patient #1 had "No actual or suspected pain."

Review of the eMAR dated 1/17/2023 at 2:43 AM revealed Patient #1 was given "...Lorazepam...1 mg...IV Push...Reason for Medication...Comfort..."

Review of the eMAR dated 1/17/2023 at 2:48 AM revealed, "...Lorazepam...Medication Administration Reason: Anxiety; Medication Response: Symptoms Improved..."

Review of the eMAR dated 1/17/2023 at 3:59 AM revealed Patient #1 was given "...morphine...1 mg...IV Push...Reason for Medication...Pain Severe..."

Patient #1 was not reassessed for pain and/or medication effectiveness until 6:26 AM, a total of 2 hours and 27 minutes later, at which time the eMAR Continuous Infusions portion revealed, "...morphine...Medication Administration Reason: Pain; Medication Response: Symptoms Improved..."Medication Effective: Yes..."

Patient #1 was transitioned to inpatient hospice care on 1/17/2023 at 12:27 PM.

8. In a telephone interview on 3/8/2023 at 3:33 PM, the Complainant, Patient #1's daughter, stated when she arrived at the hospital on the morning of 1/16/2023, she went to the nurses station to inform staff she had arrived for the day and asked which nurse would be caring for the patient that day. The complainant stated Nurse#1 stated she was the patient's nurse and told the Complainant, she had just come back from medical leave and she "was foggy." The Complainant continued and stated when she went in to see her father (Patient#1) he appeared to be in pain; he was "moaning." The Complainant stated she went back to the nurses station and asked [named Nurse #1] when was the last time the patient had any medication for pain and the nurse told her it would be another "45 minutes" before any more medication could be given. The Complainant continued and stated, "after 45 minutes she [Nurse#1] came back and put something in his arm [IV site]. I'm thinking it was morphine. After an hour and a half, he was no better. I went back to the nurse [Nurse #1] and said whatever you gave him wasn't working. She [Nurse #1] told me she gave him Zofran, not morphine or Ativan because she thought that would settle him down. She [Nurse #1] still didn't give him morphine; she gave him something else that started with an L [Lorazepam] to settle him down..."

The Complainant stated Physician #1 saw Patient #1 between 12:00 PM and 1:30 PM on 1/16/2023. The Complainant said when Physician #1 evaluated the patient, he stated "he's [Patient #1] miserable; so unsettled." The Complainant continued and stated Physician #1 told her he thought hospice would be best for the patient "so we [hospital] can start a constant Morphine drip...He said I'm writing the order now..." The Complainant stated she knew it would take a little bit of time for the pharmacy to prepare the medication and send it up.

The Complainant stated two nurses (Nurse #1 and #2) brought in the IV pole, pump, 2 IV bags and a clear cylinder. "They [the nurses] put the cylinder in a clear box and [Nurse #1] started pushing buttons and the other nurse left before [Nurse #1] finished setting up the machine." The Complainant stated Patient #1 didn't get any relief after the machine was set up. The Complainant continued and stated Nurse #1 "...appeared as if she didn't quite know how to use the machine [PCA pump]..." The Complainant then stated when the Hospice Nurse arrived at approximately 5:30 PM, the nurse looked at Patient #1 who was "moaning and groaning", then looked at the PCA pump and stated, "This machine is not on!" The hospice nurse then went directly to the nurses station and got Nurse #1. When Nurse #1 arrived in the patient's room, she told them she had to get a key to work the machine, then left the room. The Complainant then stated, "I never saw [Nurse #1] again that day." The Complainant stated the Hospice Nurse went back to the nurses station around shift change and had the evening shift nurse [Nurse #3] come into the room and showed him that the pump was not working. Nurse #3 went and got a key and came back in the patient's room and got the pump working. The Complainant stated, "Only 10 minutes and my father [Patient #1] was at peace; that's all it took!"

The Complainant stated she reported all of her concerns to the hospital's Director of Clinical Quality Improvement and Chief Nursing Officer. The Complainant continued and stated the Director of Clinical Quality Improvement was "in tears when she heard how her father [Patient #1] had suffered" The Complainant continued and stated she knew she made a scene and was inappropriate with some of her language, but she was trying her best to make sure no other patients had to suffer like her father (Patient#1) did. The Complainant then stated, "I can't get what I witnessed my father go through out of mind! I keep replaying it over and over because he [Patient #1] suffered so much!"

9. In a telephone interview on 3/15/2023 at 8:20 AM, the Hospice Nurse verified she completed the initial evaluation on Patient #1. The Hospice Nurse stated she went into the patient's room on 1/16/2023 at approximately 5:30 PM and introduced herself to the patient, his daughter (Complainant) and a male family member. The Hospice Nurse stated she looked at the patient, then noticed the PCA pump was not on so she asked the Complainant "Are they waiting on me to start the pump? The daughter [Complainant] stated, 'No, they already started the pump because he [Patient #1] was in a significant amount of pain'." The Hospice Nurse stated "I went to find the nurse [RN #1] but she was no where to be found. They [staff at the nurses station] said they would let her [RN #1] know I was there. I went back to the patient's room. I did his initial vital signs and assessed his pain level. He [Patient #1] seemed to be in quite a bit of pain. He was lethargic and everything I did he seemed to be in pain and he moaned and groaned." The Hospice Nurse then stated she and the Complainant went to the lobby area where she informed her about hospice services and they completed the admission paperwork. The Hospice Nurse stated after they completed the admission paperwork, she noticed Nurse #1 had returned to the floor and she told the nurse (Nurse #1) she could go ahead start the PCA pump. The Hospice Nurse continued and stated, Nurse #1 told her "It's [the PCA pump] already been started; I [Nurse #1] set it up myself with another nurse." The Hospice Nurse informed Nurse #1 the pump was not working, so Nurse #1 went into Patient #1's room, then came back out and said the pump was on. The Hospice Nurse stated the pump was still not on, so "the second time I told her the pump was not working, she [Nurse#1] said she was looking for a key. I don't know where she went or what she did; she just disappeared." The Hospice Nurse stated she was at the nurses station writing the orders for the patient so "I decided to talk to the oncoming nurse [Nurse #3] because it was shift change..." The Hospice Nurse stated she informed the Nurse #3 the patient's PCA pump was off. The Hospice Nurse then stated, "He [Nurse #3] looked at it [PCA pump] and verified the pump was not on. The patient's daughter [Complainant] was very upset. She went and got the Charge Nurse and went off on her. He'd [Patient #1] been in pain." The Hospice Nurse stated Nurse #3 immediately set up the pump and together, they repositioned the patient. The Hospice Nurse stated the patient was comfortable in less than 30 minutes. The Hospice Nurse was asked if it appeared any medicine had been given from the PCA pump when she first noticed it was off. The Hospice Nurse stated, "What I looked at was for the green light; it was not on. It did not appear that any medication had been given, but I cannot say for sure."

10. In an interview on 3/20/2023 at 10:20 AM, Nurse #2 was asked how she would determine if a patient was in pain. The nurse stated, "moaning, groaning or stating they were in pain." The nurse was asked how often patients should be assessed for pain and where it should be documented. Nurse #2 stated, "Every 2 hours with rounding; it's supposed to be documented under the pain assessments every 2 hours." Nurse #2 verified she was present in Patient #1's room when Nurse #1 set up the PCA pump. The nurse stated she remained in the room until the loading dose was delivered. Nurse #2 was asked if she noticed if Patient #1 responded to the medication. The nurse stated, "Not that I recall." Nurse #2 was asked if she had any other interactions with Patient #1 to see if he responded to the medication. Nurse #2 stated, " I went in to get the dirty linen bag; I didn't stay long enough to interact with the patient." Nurse #2 was asked how she would chose between Lorazepam and morphine to administer to a patient when both medications were ordered. The nurse stated, "Lorazepam is given for anxiety, agitation, and some comfort measures...give morphine for moaning and groaning or if it looks like he's [patient] in pain."

In an interview on 3/20/2023 at 10:36 AM Nurse #1 was asked how she would determine if a patient was in pain. The nurse stated, the patient might be "rubbing their legs, state it grimacing; if they are non verbal sometimes I go by the heart rate, crying out..." The nurse was asked how often patients should be assessed for pain and where it should be documented. Nurse #1 stated, "Every 4 hours; if I give medicine, within an hour to see if it's been effective. We document pain assessments under the nurses notes." Nurse #1 was asked if she could recall caring for Patient #1 on 1/16/2023. The nurse confirmed she could and stated "He [Patient #1] was a DNR, toward the latter part of my shift; he was made Hospice and given medication for transition from earthly bound to heavenly bound." Nurse #1 was asked if Patient #1 ever complained of nausea while she was providing care to him. Nurse#1 stated, "No, he was kind of a non-verbal patient; he mainly just moaned." Nurse #1 was asked how she would chose between Lorazepam and morphine to administer to a p