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Based on review of records and interview, the governing body failed to ensure that a physician was on call at all times in that 1 of 1 patient (Patient #1) did not receive pain medication in a timely manner after Physician #9's answering service was contacted by Nurse #1. On 04/11/11 at 01:25 AM, Nurse #1 requested Physician #9 to return an answering service request for a call back to discuss Patient #1's pain medication. Patient #1 did not receive the pain medication until 05:36 AM (approximately 4 hours after Physician #9 was first contacted).

Findings included:

The Discharge Summary (dictated/transcribed 04/21/11) noted that Patient #1, age 46, was admitted to the hospital on 04/07/11 with lumbar stenosis and mechanical instability. On 04/07/11, Patient #1 had a lumbar decompressive laminectomy L4-5 and L5-S1 with medial facetectomies, bilateral foraminotomies and discectomies at L4-5 and L5-S1.

The "History and Physical" unchanged as of 04/07/11 noted that Patient #1 had allergies that included morphine and Demerol.

The nursing notes indicated that on 04/11/11 at 01:25 AM, Patient #1 requested pain medication. Nurse #1 called the physician's answering service. Subsequent calls were placed to the answering service at 02:03 AM, 02:29 AM, and 03:10 AM by Nurse #1. At 04:00 AM, Patient #1 was "screaming out loud...demanding for her pain meds (medications)..." At 04:30 AM, Nurse #1 placed another call to the "answering service."

Physician #9 called back at 04:46 AM regarding the pain medication for Patient #1 and ordered Demerol. The 04/11/11 "Medication Discharge Summary" indicated that Patient #1 refused the Demerol three times. At 05:10 AM, Physician #9 was paged regarding Patient #1 being allergic to "Demerol..." At 05:36 AM, Norco was given to Patient #1 per the physician's orders. This was approximately 4 hours after Nurse #1 called Physician #9's answering service the first time.

During an interview at approximately 10:45 PM on 07/01/11, the Associate Chief Nursing Officer (Personnel #10) was asked if there were guidelines for a physician's response to a request for return contact by a nurse. Personnel #10 said that the Medical Staff had rules regarding this and there were protocols to follow if the physician was not able to be reached.

The "Medical Staff Rules and Regulations" reviewed by the Medical Executive Committee 04/13/10 and adopted by the Board of Trustees on 04/26/10 included that "Each practitioner must assure timely, adequate, professional care for his patients in the hospital by being available or having available through his office an alternate practitioner..."

The "Chain-of-Command and Administrative Call" policy #ADMIN106 revised October 2010, included that, "No more than two (2) calls will be made to the physician prior to invoking the Chain-of-Command..."

Based on review of records and interview, the hospital failed to provide 1 of 1 patient (Patient #1) care in a safe setting in that Patient #1 did not receive appropriate management of pain. Patient #1 asked for pain medication at 01:25 AM on 04/11/11 and did not receive the medication until approximately 4 hours later, at 05:36 AM. In addition, Physician #9 prescribed a medication that Patient #1's medical record indicated she was allergic to prior to Physician #9 giving an order for the correct pain medication. This practice could have presented the risk of potential harm to Patient #1.

Findings included:

The Discharge Summary (dictated/transcribed 04/21/11) noted that Patient #1, age 46, was admitted to the hospital on 04/07/11 with lumbar stenosis and mechanical instability. On 04/07/11, Patient #1 had a lumbar decompressive laminectomy L4-5 and L5-S1 with medial facetectomies, bilateral foraminotomies and discectomies at L4-5 and L5-S1.

The "History and Physical" unchanged as of 04/07/11 noted that Patient #1 had allergies that included morphine and Demerol.

The nursing notes indicated that on 04/11/11 at 01:25 AM, Patient #1 requested pain medication. Nurse #1 called the physician's answering service. Subsequent calls were placed to the answering service at 02:03 AM, 02:29 AM, and 03:10 AM by Nurse #1. At 04:00 AM, Patient #1 was "screaming out loud...demanding for her pain meds (medications)..." At 04:30 AM, Nurse #1 placed another call to the "answering service."

Physician #9 called back at 04:46 AM regarding the pain medication for Patient #1 and ordered Demerol. The 04/11/11 "Medication Discharge Summary" indicated that Patient #1 refused the Demerol three times. At 05:10 AM, Physician #9 was paged regarding Patient #1 being allergic to "Demerol..." At 05:36 AM, Norco was given to Patient #1 per the physician's orders. This was approximately 4 hours after Nurse #1 called Physician #9's answering service the first time.

During an interview at approximately 10:00 PM on 07/01/11, Registered Nurse #4 was asked what she remembered about Patient #1. RN #4 reviewed Patient #1's nursing notes and stated that she remembered that Patient #1 wouldn't listen and was screaming. She had wanted pain medication from her nurse who was contacting the physician.

The hospital's "Patient's Rights and Responsibilities" policy #ADMIN03, revised August 2009, included that "The patient has a right to appropriate assessment and management of pain. The patient can expect information about pain and pain relief measures, and a concerned staff committed to pain management."

Based on review of records and interview, the hospital failed to have a well-organized nursing service with a plan of administrative authority in that 1 of 1 patient (Patient #1) who requested pain medication on 04/11/11 at 01:25 AM did not receive the medication until 05:36 AM (approximately 4 hours after the first call to the physician's answering service by Nurse #1 and more than 2 subsequent attempts at contacting Patient #1's physician for pain management).

Findings included:

The Discharge Summary (dictated/transcribed 04/21/11) noted that Patient #1, age 46, was admitted to the hospital on 04/07/11 with lumbar stenosis and mechanical instability. On 04/07/11, Patient #1 had a lumbar decompressive laminectomy L4-5 and L5-S1 with medial facetectomies, bilateral foraminotomies and discectomies at L4-5 and L5-S1.

The "History and Physical" unchanged as of 04/07/11 noted that Patient #1 had allergies that included morphine and Demerol.

The nursing notes indicated that on 04/11/11 at 01:25 AM, Patient #1 requested pain medication. Nurse #1 called the physician's answering service. Subsequent calls were placed to the answering service at 02:03 AM, 02:29 AM, and 03:10 AM by Nurse #1. At 04:00 AM, Patient #1 was "screaming out loud...demanding for her pain meds (medications)..." At 04:30 AM, Nurse #1 placed another call to the "answering service."

Physician #9 called back at 04:46 AM regarding the pain medication for Patient #1 and ordered Demerol. The 04/11/11 "Medication Discharge Summary" indicated that Patient #1 refused the Demerol three times. At 05:10 AM, Physician #9 was paged regarding Patient #1 being allergic to "Demerol..." At 05:36 AM, Norco was given to Patient #1 per the physician's orders. This was approximately 4 hours after Nurse #1 called Physician #9's answering service the first time.

During an interview at approximately 10:45 PM on 07/01/11, the Associate Chief Nursing Officer (Personnel #10) was asked if there were guidelines for a physician's response to a request for return contact by a nurse. Personnel #10 said that the Medical Staff had rules regarding this and protocols to follow if the physician was not able to be reached.

The "Medical Staff Rules and Regulations" reviewed by the Medical Executive Committee 04/13/10 and adopted by the Board of Trustees on 04/26/10 included that "Each practitioner must assure timely, adequate, professional care for his patients in the hospital by being available or having available through his office an alternate practitioner..."

The "Chain-of-Command and Administrative Call" policy #ADMIN106 revised October 2010, included that, "No more than two (2) calls will be made to the physician prior to invoking the Chain-of-Command..."