HospitalInspections.org

Based on staff interview, review of two of 10 medical records (#1, #8), and review of facility documents, it was determined the facility failed to ensure that pain assessments for patient's on End of Life Care, is performed in accordance with facility policy.

Findings include:

Reference: Facility Policy titled, "End of Life Care (Comfort Care)" (approved 6/5/23) states, "... FLACC- a behavior pain assessment scale for use in non-verbal patients unable to provide reports of pain. A behavior scale for scoring pain in no-communication patients which includes (F) facial expression, (L) leg movement, (A) activity level, (C) crying, and (C) consolability scored from 0 to 2 resulting in a total score of 0 to 10 ... Procedure: ... 1. The patient's symptoms will be assessed based on the FLACC scale for pain ... and the drip titrated appropriately."

On 12/28/23 at 1:00 PM, a review of Patient (P)1's medical record was conducted with Staff (S)4 (Clinical Informatics). P1 presented to the facility on 12/01/23 for inpatient hospice care and had a history of metastatic pancreatic cancer. P1 expired at the facility on 12/15/23 at 12:26 PM.

The physician order for Hydromorphone IV (Intravenous) infusion dated 12/10/23 at 17:28 [5:28 PM] was reviewed and indicated that the Hydromorphone IV drip should be titrated for P1's comfort.

All nursing assessments dated 12/01/23 to 12/15/23 were reviewed and indicated the facility performed verbal pain assessments on 12/1/23, 12/2/23, and 12/3/23 when the patient was alert and oriented. However, there was no evidence the FLACC Scale was used for pain assessments from 12/4/23 to 12/13/23 when the patient was non-verbal and unable to provide a verbal pain score.

On 12/28/23 at 2:00 PM, P8's medical record was reviewed with S4. The medical record indicated P8 was placed on hospice care on 4/1/23 and expired on 4/7/23. Review of P8's medical record revealed the following:

The following physician's orders were entered for P8:

On 4/1/23 at 11:07 AM, Morphine drip 100 mg (milligrams) in Sodium Chloride 100 mL (milliliters) at a rate of 0.5 mL/hr (hour): Titrate to Air Hunger, Dyspnea, Comfort.

On 4/4/23 at 10:15 AM, Lorazepam (Ativan Injection) 2 mg/mL IV (intravenous) Push every two hours PRN (as necessary), for agitation for seven days.

On 4/4/23 at 10:16 AM, Morphine 2 mg/mL IV push every hour, PRN for Air Hunger.

The Medication Administration Record (MAR) was reviewed and revealed that the morphine, starting on 4/1/23, was titrated over five days from 0.5 mg/hr up to 18 mg/hr on 4/6/23. The MAR lacked documented evidence of a nursing assessment and reassessment when the morphine infusion rate was increased on the following dates:

4/1/23 11:10 PM - the morphine drip was increased from 0.5 mg/hr to 1 mg/hr (milligram/hour)

4/2/23 at 11:37 AM - the morphine drip was increased to 2 mg/hr from 1 mg/hr

4/2/23 at 10:06 PM - the morphine drip was increased to 3 mg/hr from 2 mg/hr

4/3/23 at 1:57 AM - the morphine drip was increased to 4 mg/hr from 2 mg/hr

4/3/23 at 8:45 AM - the morphine drip was increased to 5 mg/hr from 4 mg/hr

4/3/23 at 7:00 PM - the morphine drip was increased to 6 mg/hr from 5 mg/hr

4/4/23 3:32 AM - the morphine drip was increased to 10 mg/hr from 9 mg/hr

4/4/23 9:30 AM - the morphine drip was increased to 11 mg/hr from 10 mg/hr

4/5/23 5:49 AM - the morphine drip was increased to 12 mg/hr 11 mg/hr

4/5/23 10:14 PM - the morphine drip was increased to 16 mg/hr from 12 mg/hr

4/6/23 5:19 AM - the morphine drip was increased to 17 mg/hr from 16 mg/hr

4/6/23 9:50 PM - the morphine drip was increased to 18 mg/hr from 17 mg/hr

The rate of the morphine drip remained at 18 mg/hr until P8 expired on 4/7/23 at 3:51 AM. A review of P8's medical record lacked documentation of a pain assessment using the FLACC pain scale prior to increasing the morphine drip rates in the above dates.

S4 confirmed the above findings at the time of discovery.