HospitalInspections.org

Based on interview and review of 6 patient records, it was determined that the hospital failed to ensure that a Registered Nurse evaluated the nursing care of 1 of 6 sampled patients.

Findings include:

Patient #1 was a 47 year-old person who fell and injured his/her right wrist. The patient was seen in the Emergency Department on 11/23/11 at 0226 hours, and discharged 1 hour and 23 minutes later, on 11/23/11 at 0349 hours, with a splint, a sling, and a referral to Willamette Orthopedic Group for a diagnosis of a minimally displaced fracture of the right wrist. The patient record reflected that during this period of time, an x-ray was taken, and a single injection of Morphine 10 milligrams was administered intramuscularly at 0256 hours-30 minutes after the patient's admission, and 53 minutes prior to the patient's discharge from the Emergency Department. Documentation reflected neither relief of pain, nor complaints of continued pain after the pain medication was administered.
In an interview with I2 at 0930 hours on 04/29/11 in the hospital's administrative office, I2 presented a notebook titled: " Patient Care Guide. " I2 explained that copies of this notebook had been placed at the bedside table of every patient room in the hospital. The Patient Care Guide listed a table of contents which included, but was not limited to, the following information:
Encouragement to "speak up" and to use the hospital's "HELP" line if a patient felt his/her concerns were not being heard, or if the patient felt his/her pain had not been appropriately assessed; medication information; instructions pertaining to filing a complaint.
I2 also presented a tri-fold brochure titled: "The Patient at Salem Hospital," which s/he stated had been given to each patient at the time of admission to the hospital for services. This brochure contained a listing of patient rights, including the following:
"A patient's pain will be appropriately assessed and managed."
Pain, and the effects of an injectable medication on that pain, had not been quantified or assessed in patient record #1. The patient's response to interventions for pain had not been evaluated by a Registered Nurse, as required by this regulation.