HospitalInspections.org

A. Based on document review and interview, it was determined that for 1 (Pt. #1) of 10 clinical records reviewed for pain, the Hospital failed to document interventions to address Pt.#1 being uncomfortable and shaking.

Findings include:

1. On 10/5/16 at approximately 2:00 PM, the Hospital's policy titled, "Pain Assessment and Management," (revised 9/15) indicated, "... Procedure:...4. If pain ... is unacceptable to the patient, or if non-verbal cues are noted, there will be an intervention intended to reduce the pain..."

2. On 10/4/16 at approximately 11:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 23 year old female patient admitted on 7/21/16 with the diagnosis of Oligohydramnios (a condition that can develop during pregnancy when not enough amniotic fluid, which surrounds the fetus, is produced) and term pregnancy. On 7/21/16 at about 8:20 PM, a pain assessment was conducted as patient was experiencing rectal and pelvic pressure. At 8:21 PM, Pt. #1's behavior was noted as shaking and more uncomfortable. However, Pt. #1's clinical record lacked documentation that an intervention was provided to address the pain.

3. On 10/05/16 at approximately 4:00 PM, finding was discussed with E #1 (Director of Women's and Children's Services) who agreed that there was no documentation of an intervention provided to Pt. #1.

B. Based on document review and interview, it was determined that for 1 (Pt. #1) of 10 clinical records reviewed for pain, the Hospital failed to document an hourly evaluation and assessment of pain.

Findings include:

1. On 10/5/16 at approximately 3:00 PM, the Hospital's policy titled, "Nursing Assessment and Management of the Woman Receiving Regional Analgesia in Labor," (reviewed 10/15) indicated, "... Post-Procedure Maternal and Fetal Assessment: ... 5. Evaluate and document maternal pain levels, using the pain scale 30-60 minutes post-procedure and hourly thereafter. Notify the anesthesiologist if adequate pain relief is not obtained."

2. On 10/5/16 at approximately 3:15 PM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 23 year old female patient admitted on 7/21/16 with a diagnosis of Oligohydramnios and term pregnancy. Pt. #1 had an epidural (a regional anesthesia used to block pain) procedure completed on 7/21/16 at 6:12 PM. However, the following were noted between 7/21/16 to 7/22/16:

- Hourly pain assessment was not done from 6:36 PM to 8:19 PM (total of 1 hour and
43 minutes)
- Hourly pain assessment was not done from 8:21 PM to 1:30 AM
(total of 5 hours and 9 minutes)
- Hourly pain assessment was not done from 2:30 AM to 3:59 AM (total of 1 hour and
29 minutes)
- Hourly pain assessment was not done from 4:46 AM to 6:23 AM (total of 1 hour and 37
minutes)

3. On 10/05/16 at approximately 4:00 PM, findings were discussed with E #1 who acknowledged that there were periods of time between 7/21/16 to 7/22/16 in the clinical record of Pt. #1 when hourly pain assessments were not documented.