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Observation and review of one out of 15 sampled patient medical reviews, it was determined that the hospital staff (physician and nursing staff) failed to provide Patient #2 an opportunity to participate in the development and implementation of a care plan specific to pain management while hospitalized and prior to discharge. See A-0396 for details, Patient #2.

Observation and review of two out of 15 sampled patient medical reviews, it was determined that the hospital staff (physician and nursing staff) failed to ensure that the patients' care plans were implemented, revised to identify, address and manage patient needs while hospitalized and at time of discharge.
The findings were:
Patient #1 was 93 years old and was admitted to the Intensive Care Unit (ICU) through the emergency department from a Long Term Care facility on 12/0/13 for an altered mental state, hypertension, and a gastrointestinal bleed. The patient had other medical conditions such as: recurrent falls, failure to thrive, and Alzheimer ' s dementia. The patient was incontinent of bowel and bladder and dependent for all Activities of Daily Living (ADLs). The patient was a Full Code while in the hospital and certified on 11/25/13 by a physician as incapable of understanding or making informed decisions about medical care.
The nursing staff assessed the patient ' s skin status between 12/04/13-12/09/13 with a score ranging between 9-10 (Braden Scale-pressure ulcer risk development rating system, 9-10 high risk-very high risk), patient activity as bedfast, sensory perception limited, and poor nutrition.
A review of the patient 's documented turning and repositioning records (contained in the " skin nurse documentation " area of the electronic medical record) revealed that the patient was not consistently turned and repositioned every two hours to off load pressure on the buttock and back area for long periods. Periods of time between the patient's turning and positioning ranged from five hours up to 11 hours. This was observed and evident in five noted times of turning and positioning between 12/04/13 and 12/07/13. By 12/09/13 the patient was assessed by the nursing staff as having developed a sacral wound measuring in length of 5 centimeters(cm), width of 4cm, and depth 0.1cm. The area was cleansed and dressed with a no sting barrier film.
The patient was discharged on 12/16/13 back to the Long Term Care facility. Observation and review of the physician's Transfer/Discharge Summary made no mention of the patient's skin status (sacral wound) at the time of discharge and the needed care. Therefore, the Transfer/Discharge Summary was incomplete, potentially placed the patient at risk for having a lack of continuity in care and a delay in treatment. A similar observation was made on a second physician Transfer/Discharge Summary dated 12/28/13 for the patient's second hospitalization, when the patient was discharged back to the Long Term Care facility. The physician refers to the application of Santyl Cream (enzymatic topical debriding agent) daily, but lacked specification of where the cream was to be applied and why.

Patient #2 was 62 years old, admitted through the emergency department on 01/29/14 from the hospital surgical holding area for hypotension (80/50 mmHg ) and hypoxia(oxygen depletion). The patient was scheduled for a right total hip hemiarthroplasty ( femoral head replacement). The patient received Narcan1.2mg in the emergency department and improved. The patient had other medical conditions which included: chronic pain, diabetic neuropathy, chronic kidney disease, and a history of deep venous thrombosis (DVT-clot).

During the tour of 4 East at 9:00AM and interview of the patient, the patient stated that he had been in pain for days without relief since admission of 01/29/14. The patient also, mentioned that he had been under the care of a pain management specialist for two years. The patient described the pain as "constant pain" in the left ankle, right knee, right hip, and shoulder ranging between 7/8 and at times 10/10. The patient commented that the nursing staff would provide him the pain medication when called, however, it would always be 30-45 minutes after the request was made. The patient stated that when pain medications are taken timely and in a regular manner the pain level remains at about a 6.

Additional interview of the patient at 10:45 AM in the patient ' s room, revealed that none of the current physicians providing him care had discussed obtaining a pain management consult nor had he seen any physician in the hospital to date for that assistance. The patient also stated that he was scheduled for discharge at some point to attend rehabilitation.

A review of the patient's medical record (orders and a physician progress note) revealed that the patient's treatment team had not identified and addressed the patient ' s chronic pain through a pain management consult until surveyor inquiry. At 14:15 on 02/11/14 the nursing staff administered pain medication (Dilaudid 4 mg orally) to the patient for discomfort and obtained a telephone order at 16:05 for a pain consult [Dr.H.]. The patient was discharged on 02/11/14 in the afternoon to the subacute rehabilitation unit located on the hospital grounds. Review of the patient's pain assessments revealed that nursing staff inconsistently documented the patient ' s pain score both before and after pain medication administration.

Additional consultation with the nursing and IT staff of the hospital revealed that on 02/05/14 a pain management consult was ordered for the patient, but was not contained in the patient ' s routine electronic orders (order set). The Director of IT/Informatics explained to the surveyor that the order had been grouped into another area of electronic records, not within the view of care staff to know to follow the order, and that the order was extremely difficult and arduous to find.

The hospital staff failed to ensure that the patient ' s care plan identified, assessed, and addressed the patient ' s chronic pain through pain management consultation during hospitalization and prior to the patient ' s discharge, creating a delay in treatment and patient's continued discomfort.

Observation and review of two out of 15 sampled patient medical reviews, it was determined that the hospital staff (physician and nursing staff) failed to ensure that Transfer/Discharge Summaries identify and address all of a patient's needs for continuity of care and related follow up. See A-0396 for details, Patient #1.