HospitalInspections.org
Bringing transparency to federal inspections
BAYLOR SCOTT & WHITE MEDICAL CENTER GRAPEVINE
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on interview and record review, the facility's registered nurses did not supervise and evaluate the nursing care for 1 of 1 patient (Patient #1) in that, there were no reassessments performed after administering pain medications on 11/29/19, 11/30/19, and 12/01/19. The patient was in severe pain and returned to the operating room twice during his confinement with an admission date of 11/23/19.
Findings included:
Patient #1 had an initial surgical procedure: laparascopic splenectomy on 11/25/19. On 11/29/19 at 11:21 PM, Morphine 4 mg was given for pain. No nursing reassessment was done.
On 11/30/19 at 9:09 AM, Patient #1's level of pain was at 7 and oxycodone was provided. No nursing reassessment was conducted. At 6:37 PM, the pain was at 6 and oxycodone was given. No reassessment was performed.
On 12/01/19 at 5:03 PM the patient's pain was at 7. Two oxycodone tablets were given. No reassessment was done. At 11:21 PM, the pain level was at 6 and 2 tablets of oxycodone were given. No reassessment was performed.
During an interview on 12/16/19 at 1:32 PM, Personnel #3 was with the surveyor reviewing the patient's medical record and confirmed that the nurses did not conduct a reassessment after providing pain medications. Personnel #3 was asked what the timeframe was for the reassessment. Personnel #3 replied within the hour.