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Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.23 Nursing Services was out of compliance.

A-0395 - A registered nurse must supervise and evaluate the nursing care for each patient. Based on document review and interviews, the facility failed to ensure patients received effective pain management in one of three medical records reviewed. (Patient #2)

Based on document review and interviews, the facility failed to ensure patients received effective pain management in one of three medical records reviewed. (Patient #2)

Findings include:

Facility policies:

The Pain Management policy read, the facility recognizes and supports the rights of all patients to receive appropriate assessment and management of pain via a patient-centric approach. All inpatients will be assessed for the existence and presence of pain upon admission, per unit standard, and as needed. If pain is present, the nature of the pain will be assessed. Using the pain scale based on appropriate age, documentation will include location, intensity, and quality of pain. All patients will be educated on the pain scale based on age, language, and developmental assessment. Functional goals for pain management and progress toward goals will be documented in the inpatient setting each shift. Timely administration of pain medication is provided as prescribed. Reassessment of the effectiveness of pain management interventions is a continuous process. When possible, reassessment is expected approximately 60 minutes after pain medication is administered.

The Standards of Care for Assessing/Reassessing Patients policy read, all patients will receive an initial assessment by a registered nurse (RN) and subsequent reassessment, based upon their age, patient care setting, and individual needs. Nursing reassessment for inpatients will occur at a minimum of every 12 hours. Physical assessment for nursing includes: vital signs (VS), diagnosis or signs/symptoms, response to prior treatment, pain (location, quality, and intensity), and more. All patients who experience pain with an intervention for pain must be reassessed following parameters set forth in the Pain Management policy.

The Venous Access Device Insertion, Maintenance, and Removal policy read, its purpose was to outline the insertion, access, maintenance, and removal practice expectations for venous access devices (VAD), including peripheral, midline, and central line devices. Peripheral VAD should be changed when clinically indicated based on findings from site assessment or clinical signs and symptoms of complications. Documentation of VAD care will be completed in the Lines, Drains, and Airways section of the electronic health record (EHR). Prompt removal of a VAD should occur when the VAD is no longer needed and must be supported by a provider order. If the VAD is discontinued prior to discharge, and the patient is expected to remain in the care of the facility, approval of the provider, in the form of an order, is needed for the patient to remain without intravenous (IV) access.

References:

The Adult Line Access Reference Guide read, peripheral IVs are to be flushed with two to three milliliters (mL) of normal saline (NS) every 12 hours and after intermittent drugs or infusions. Transparent dressing changes are to be completed every seven days and as needed.

The Patient Rights and Responsibilities brochure read, we adopt and affirm as policy the following rights of patients/clients who receive services from our facility: to appropriate assessment and management of pain.

1. The facility failed to ensure patients received effective pain management and had IV access available in accordance with facility policy.

A. Document review

i. Patient #2's medical record was reviewed and revealed Patient #2 was an 80-year-old who arrived at the facility's emergency department (ED) on 2/11/25 by ambulance with a chief complaint of fatigue and shakiness. Patient #2 was evaluated by the ED provider and sent for a CT scan (special x-rays that provide detailed images of the inside of the body). The medical record revealed the CT scan showed Patient #2 had multiple cancerous lesions of the liver and abdomen. Patient #2 was admitted to the hospital for further care of newly diagnosed metastatic cancer (cancer that had spread from its original location to other parts of the body).

Review of Patient #2's nursing care revealed on 2/18/25, seven days after admission, Patient #2 began to experience increased abdominal pain. At 6:17 p.m., Patient #2 described their pain as constant and a 7 on a scale of 1 to 10, with 10 being the worst pain. Patient #2 was prescribed and given oxycodone (a powerful pain reliever used to manage moderate to severe pain) 5 milligrams (mg) orally. Patient #2 was reassessed at 7:45 p.m., and their pain level had improved to a 5.

Patient #2's medical record also revealed on 2/19/25 at 12:02 a.m., Patient #2 was medicated with oxycodone 5 mg orally for pain described as aching abdominal pain 7 of 10. Patient #2's nursing documentation revealed they had been reassessed at 2:41 a.m., almost three hours later, and their pain level remained 7 of 10. The record revealed no pain medication was given, and there was no documentation the physician had been notified to obtain additional pain medication orders to alleviate Patient #2's pain.

This was in contrast to the Pain Management policy which read, the effectiveness of pain management interventions should have been reassessed approximately 60 minutes after pain medication had been administered.

Further review of the record revealed nursing documentation on 2/19/25 at 7:30 a.m. read, Patient #2's pain was notably high, 8 of 10. Additionally, the nursing notes read, Patient #2 had no IV access. Documentation revealed the nurse administered oxycodone 5 mg orally at 7:34 a.m. and then prioritized establishing IV access for pain control. The medical record revealed the primary nurse tried twice to insert an IV without success and then asked the charge nurse to start the IV. The record revealed the charge nurse also had difficulty obtaining IV access, so the nurse contacted the ICU charge nurse to assist with getting Patient #2's IV started. The physician had written an order for IV morphine (a powerful pain medication used to treat severe pain) to be given as soon as IV access had been obtained.

This was in contrast to the VAD policy which read, all patients should have had IV access unless there was a physician's order to remain without IV access. Review of Patient #2's medical record revealed nursing documentation on 2/19/25 at 2:46 a.m. read, Patient #2 had two VAD in place. One IV site was located in the left posterior forearm and had been placed 2/12/25, seven days earlier. A second IV was located in the right antecubital (front of the elbow) and had been inserted on 2/11/25, eight days previously. Further, documentation revealed the last time an IV medication had been administered was on 2/17/25 at 3:39 p.m. The record revealed no documentation either IV site was patent or had been flushed every 12 hours per facility policy.

Finally, the record revealed on 2/19/25 at 8:32 a.m., the nurses were at the bedside with Patient #2, who was in severe pain but had been cooperative while the nursing team attempted to insert an IV. The primary nurse documented Patient #2 suddenly developed a leftward gaze and their breathing became labored. A rapid response was called at 8:36 a.m. The rapid response team arrived at Patient #2's bedside, and because Patient #2 had a do-not-resuscitate (DNR) order, no resuscitation efforts were initiated. Patient #2 expired at 8:40 a.m.

These events were in contrast to the Pain Management policy which read, the facility recognized and supported the right of all patients to receive appropriate assessment and management of pain.

B. Interviews

i. On 5/8/25 at 10:39 a.m., an interview was conducted with registered nurse (RN) #1. RN #1 stated during each shift assessment, they took VS, assessed pain, assessed symptoms, and flushed their patients' IVs. RN #1 stated the IV flush was important to ensure the IV worked in case there was an emergency. RN #1 stated peripheral VAD should have been flushed each shift per policy, but there had been no expectation to document the flushes. Also, RN #1 stated the removal of a VAD should have been documented under the lines, drains, and airways section of the shift assessment. RN #1 stated patients were required to have an IV or a physician order that stated the patient could have remained on the unit without an IV. RN #1 stated the risk to patients in an emergency, if there was no IV access, could have been a delay in receiving treatment with urgently needed IV medications.

ii. On 5/7/25 at 10:22 a.m., an interview was conducted with clinical nurse coordinator (CNC) #2. CNC #2 stated they had been at Patient #2's bedside on the morning of 2/19/25. CNC #2 stated the primary nurse had given oral pain medication and tried two times to put in an IV without success. CNC #2 stated the primary nurse had reached out to the physician for additional pain control medications. CNC #2 stated they also tried two times to get an IV started. CNC #2 stated they could not get the IV started either, so they had called the ICU charge nurse from Patient #2's bedside to come start the IV. CNC #2 stated they did not know when Patient #2 had lost IV access. CNC #2 and the primary nurse were at Patient #2's bedside along with a family member. CNC #2 stated Patient #2 was in pain yet conversant and cooperative until a rapid change in condition at 8:32 a.m., at which time they had called a rapid response. CNC #2 stated Patient #2 was a DNR, so the physician who responded stopped resuscitation efforts and pronounced Patient #2 had expired at 8:40 a.m.

iii. On 5/7/25 at 12:37 p.m., an interview was conducted with nurse manager (Manager) #3. Manager #3 stated pain assessment should have occurred during shift assessment and as needed if the patient reported pain. Manager #3 stated reassessment of pain should have occurred one hour after oral pain medications had been administered or 30 minutes after IV pain medication had been administered. Also, Manager #3 stated all inpatients should have IV access, and a physician's order would have been required for a patient to remain without an IV. Manager #3 stated loss of IV access should have been documented in the medical record and passed on in the nursing shift-to-shift report. Manager #3 stated they had not been present on 2/19/25 for Patient #2's rapid response, nor had they reviewed Patient #2's medical record. Manager #3 stated the patient advocate team would have completed the review of Patient #2's care.

On 5/8/25 at 11:08 a.m., a second interview was conducted with Manager #3. Manager #3 stated VAD should have been changed every seven days or sooner if needed. Manager #3 also stated VAD should have been flushed before and after giving IV medications or at least once each shift, to ensure the IV was working properly. Manager #3 stated there was no place in the electronic health record (EHR) to document the flushes or that the IV was working. Manager #3 stated peripheral IVs did not have scheduled flushes or documentation in the medication administration record (MAR). Manager #3 stated ensuring IVs were flushed per policy was practice-related, and nurses should have held each other accountable.

These interviews were in contrast to the medical record review which revealed no documentation Patient #2's IV accesses, which were seven and eight days old, had been flushed, replaced, or removed.

iv. On 5/7/25 at 4:44 p.m., an interview was conducted with director of acute care (Director) #4. Director #4 stated they were on the unit the morning of 2/19/25 to support the staff during Patient #2's rapid response. Director #4 recalled they heard the charge nurse say they needed to help start a new IV so they could give Patient #2 IV pain medication. Director #4 stated they were not aware why Patient #2 had no IV access. Also, Director #2 stated they had not done a detailed review of Patient #2's nursing care.

v. On 5/7/25 at 3:45 p.m., an interview was conducted with patient liaison/quality coordinator (Coordinator) #5. Coordinator #5 stated they had been involved with the review of Patient #2's care. Coordinator #2 stated the nurse manager would have reviewed Patient #2's record and completed the investigation of nursing care.

This was in contrast to Manager #3 and Director #4's interviews, in which they both stated they had not reviewed Patient #2's nursing care.

On 5/8/25 at 10:12 a.m., a second interview was conducted with Coordinator #5. Coordinator #5 stated, a letter to Patient #2's family had read, Patient #2 self-removed their IV during the night. However, Coordinator #5 stated they had no documentation to support Patient #2 had self-removed their IV during the night.