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Based on hospital policy review, medical record review, observation and staff interviews, the nursing staff failed to assess vital signs, level of consciousness and pain per hospital policy for 2 of 2 (#5 and #6) patients receiving Patient Controlled Analgesia (PCA).

Findings include:

Hospital policy review on 03/17/2016 revealed "PCA (Patient Controlled Analgesia): PATIENT CARE" reviewed/revised 12/15. Review of the policy revealed "This policy sets forth the guidelines for the care of the patient receiving PCA. . . 3. RR, HR, BP, Sedation/LOC [respiratory rate, heart rate, blood pressure, sedation/level of consciousness], Pain Assessment . . . Frequency: every 1 hour for 4 hours, then every 4 hours. 1. Frequency begins AFTER PCA therapy is started. 2. Restart frequency AFTER any change in medication, any increase in dose, or any change in time interval. . . "

1. Open medical record review for Patient #5 on 03/15/2016 revealed a hospital admission on 03/11/2016 for exacerbation of Crohn's Disease (chronic inflammatory bowel disease), nausea and vomiting and acute kidney injury. Review of the physician's orders revealed an order for Patient Controlled Analgesia (PCA) on 03/14/2016. Review of nursing progress notes for 03/14/2016 revealed the PCA had been initiated on 03/14/2016 at 1103. Continued review revealed the patient's respiratory rate, heart rate and blood pressure measurements were obtained at 1200, 1300 and 1620. Continued review revealed pain assessments at 1103, 1543 and 1828. Further review revealed sedation/level of consciousness assessment at 1118 and 2223. The PCA assessments were not obtained every one hour for four hours per the hospital policy.

Interview with Patient #5 on 03/15/2016 at 1120 revealed the patient was receiving PCA pain medication via an intravenous line and pump.

Interview on 03/17/2016 at 1330 with the Assistant Vice President of Nursing revealed patient assessments of vital signs, level of consciousness/sedation and pain should be conducted every one hour for four hours at the start of PCA for each patient. The interview revealed Patient #5 had not been assessed per hospital policy.

2. Open medical record review for Patient #6 on 03/17/2016 revealed a hospital admission on 03/15/2016 for a right total knee replacement. Review of physician's orders revealed an order for Patient Controlled Analgesia (PCA) on 03/16/2016. Review of nursing progress notes revealed PCA was started at 0627 on 03/16/2016. Continued review revealed the patient's respiratory rate, heart rate and blood pressure measurements were obtained at 0627, 0750 and 1141. Continued review revealed pain assessments at 0627 and 0742. Further review revealed sedation/level of consciousness assessment at 0627 and 0742. The PCA assessments were not obtained every one hour for four hours per the hospital policy.

Interview on 03/17/2016 at 1330 with the Assistant Vice President of Nursing revealed patient assessments of vital signs, level of consciousness/sedation and pain should be conducted every one hour for four hours at the start of PCA for each patient. The interview revealed Patient #6 had not been assessed per hospital policy.

Based on observation and staff interview, the nursing staff failed to identify expired medication available for patient use for 10 of 15 Normal Saline 5 milliliter (ml) syringes for injection.

Findings include:

Observation on 03/15/2016 at 1120 duing a tour of the sixth floor medication room, revealed ten Normal Saline 5 ml syringes for injection that had expired on 11/01/2015 that were available for patient use. The observation revealed the 5 ml Normal Saline syringes were in a bin beside the computerized medication system.

Interview with the Assistant Vice President of Nursing at the time of the observation revealed the syringes were monitored by the medical supply staff and the nursing staff on the unit. The interview revealed the syringes should have been removed and disposed of in the SHARPS container at time of expiration.