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KINDRED HOSPITAL - CHICAGO
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on document review and interview, it was determined that for 1 (Pt. #6) of 3 clinical records reviewed for pain management, the Hospital failed to ensure that the physician was notified, as required, for ineffective pain management.
Findings include:
1. On 11/7/17 the policy entitled, "Pain Management Plan" (release date 9/2017) was reviewed and required, "Procedure: 1. a...Ongoing pain assessment and reassessments are performed by licensed nurses...when a patient complains of pain and after analgesic is given to determine effectiveness of the analgesic...c. v. The licensed nurse shall communicate the adequacy of pain management and/or changes in pain significance to the physician...as needed based on ...reassessment data... vi. Failure to relieve pain is reported as soon as possible to the physician and other staff as needed using the facility specific communication process."
2. On 11/7/17 at approximately 2:35 PM, the clinical record of Pt. #6 was reviewed. Pt. #6 was a 65 year old male admitted on 10/17/17 with a diagnosis of early complication of trauma. Pt. #6's clinical record contained a physician's order dated 10/26/17 at 2:19 PM for Hydrocodone 5/325 milligrams (pain medicine) every four hours as needed for moderate pain.
On 11/3/17 at 3:30 PM Pt. #6 received a dose of hydorcodone for a constant, sharp and stabbing pain to the upper abdomen . The pain was rated on a pain scale of 0-10 (0 indicated no pain and 10 the most severe pain ever experienced) as a "10". On 11/3/17 at 4:30 PM, the pain reassessment was conducted, and the nurse documented that the medication was "not effective" and that on a pain scale, Pt. #6 rated his pain at "10". The clinical record lacked documentation of notifying the physician that pain medication was not effective or any additional interventions attempted.
3. On 11/7/17 at approximately 2:45 PM, the Nurse Manager of 3 East (Medical Surgical Unit) (E #3) was interviewed. E #3 stated that the nurse should have notified the physician that the pain medication was not effective.