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Based on medical record review, policy and procedure review, and staff interview it was determined the facility failed to ensure nursing staff provided interventions for a patient identified with pain for one (#2) of ten patients sampled; failed to assess the patient's pain level prior to providing pain medication and following administration of pain medication for one (#4) of ten patients sampled; and failed to ensure two (2) physician ordered consultations were completed for one (#2) of ten patients sampled.

Findings include:

1. Review of the medical record for patient #2 revealed the patient was admitted to the facility on 9/18/2013. Review of nursing documentation revealed on 9/19/2013 at 3:12 p.m., the patient complained of back pain of 8 out of 10 with 10 being the worst possible pain. Review of the nursing documentation and MAR (Medication Administration Record) revealed the patient was medicated for pain at 7:01 p.m., approximately four (4) hours after complaining of pain. Review of the nursing documentation revealed no alternative interventions were offered or provided during those four hours. Interview with the Clinical Educator and Chief Nursing Officer on 11/26/2013 at approximately 2:30 p.m., confirmed the findings.

2. Review of the medical record for patient #4 revealed the patient was admitted to the facility on 9/21/2013 status post a fall at home. Documentation revealed the patient sustained a fractured ankle requiring surgical repair. Review of the MAR revealed on 9/21/2013 at 9:57 p.m. Morphine 4 mg (milligrams) was administered IV (Intravenously). Review of the nursing documentation revealed no evidence the patient's pain level was assessed prior to administration of the Morphine. Review of the nursing documentation revealed no evidence the patient's pain level was assessed post administration of the Morphine. There was no documentation to reveal if the pain medication was effective.

On 9/22/2013 at 3:38 a.m. Morphine 4 mg IV was administered. Review of the nursing documentation revealed no evidence of a pre or post pain level assessment. There was no documentation to reveal if the pain medication was effective for the patient's pain.

Review of the facility, "Pain Management", #PC 350, last approved 6/2012, states (II) Intervention, (D) re-evaluation occurs within 30 minutes to 1 hour following intervention, with documentation of the time; pain score, level of sedation, descriptors and/or non-verbal signs. Interview on 11/26/2013 at 11:30 am with the Clinical Educator confirmed the above findings.

3. Review of the medical record for patient #2 revealed the patient was admitted to the facility on 9/18/2013. Review of the physician orders revealed on 9/19/2013 at 6:15 am a pain management consultation was ordered. Review of nursing documentation on 9/19/2013 at 5:32 p.m., stated pain consultation not placed earlier, consult called by secretary. Review of the record revealed the consultation was not completed as ordered. The patient was discharged on 9/20/2013.

Review of the physician orders revealed on 9/18/2013 at 7:00 p.m., a pulmonologist radiologist consultation was ordered. Review of the medical record revealed no evidence the consultation was completed. Interview with the Chief Nursing Officer on 11/26/2013 at approximately 2:30 p.m., confirmed the findings.

Based on medical record review, staff interview, and review of policy and procedure it was determined the facility failed to ensure the nursing staff kept current the nursing care plan and reviewed it daily for one (#2) of ten patients sampled.

Findings include:

Review of the medical record for patient #2 revealed the patient was admitted to the facility on 9/18/2013 with a diagnosis of Pulmonary Embolus. Review of the patient's interdisciplinary plan of care revealed nursing identified knowledge deficit, discharge planning, safety, and pain as the focus areas. Review of the plan of care revealed no evidence nursing identified airway management/gas exchange as a focus area. The patient's admitting diagnosis was pulmonary embolus and documentation revealed the patient had abnormal breath sounds, complained of a cough, and chest discomfort.

Review of the medical record revealed a pulmonologist evaluated the patient on 9/19/2013 and documented the patient had symptoms of gastroesophageal reflux disease, chronic obstructive pulmonary disease, and was a heavy smoker. Review of the patient's plan of care on 9/19/2013 and 9/20/2013 revealed no further documentation.

Review of the facility policy, "Assessment and Reassessment," last approved 11/2012, states the patient plan of care will be reviewed at least daily by an RN. Interview with the Clinical Educator and Chief Nursing Officer on 11/26/2013 at 2:30 p.m., confirmed the findings.

Based on medical record review and staff interview it was determined the facility failed to ensure nursing staff administered medication according to physician orders for one (#2) of ten patients sampled.

Findings include:

Review of the medical record for patient #2 revealed the patient was admitted on 9/18/2013. Review of the physician orders revealed on 9/19/2013 at 8:24 am an order for Solumedrol 30 mg (milligrams) IV (Intravenous) every 12 hours. Review of the MAR (Medication Administration Record) revealed the first dose of Solumedrol was administered on 9/19/2013 at 11:33 pm, approximately 15 hours after the physician order was written. Review of the record revealed no evidence or documentation to explain the delay in providing the medication. Interview with the Clinical Educator on 11/26/2013 at approximately 11:15 am confirmed the findings.