HospitalInspections.org

Based on interview, record review and a review of facility documentation, the facility failed to ensure that drugs in the form of Dilaudid were administered by nursing in accordance with policies regarding vital sign assessments in one of five sampled patients. (#1)

Findings:

A review of the medical record of patient #1 was performed. The patient arrived in the ER on 12/31/09 at 7:13 a.m.. The nursing assessment, written at 7:18 a.m. read: "Alert, oriented and fully verbal. Needs one on one assistance to get around. ... Alert and oriented X 3. Speech clear. Responds to commands. Moves all extremities. ... Bilateral breath sounds clear. Respirations regular and unlabored. ... Pulse regular, no complaint of chest pain. ... Patient complains of pain affecting right side of chest under right breast. Pain described as sharp. The pain is deep. Pain is constant". An exam by the physician began at 7:51 a.m.. He wrote: "Abdominal pain is sharp and stabbing. Complains of generalized abdominal pain. Severity - currently rather mild. Developed rapid onset abdominal pain. Pain is really quite constant. These symptoms seem to be slowly progressing".

The Emergency Room physician ordered "ED Dilaudid IV 1 MG IV once" at 8:02 a.m.. The nurse wrote at 08:00 a.m.: "Patient given first dose slow IV push. IV capped and flushed. Just given ED Dilaudid IV. Awake and alert. Excruciating pain (pain scale = 10/10)". The physician ordered "ED Dilaudid IV 1 MG IV once" at 8:02 a.m.. A nurse's note at 8:12 a.m. read: "Patient given second IV dose slow IV push. IV capped and flushed. Just given ED Dilaudid IV. Awake and alert". The physician ordered "ED Dilaudid IV 1 MG IV once at 8:43 a.m.. A nurse's note at 8:48 a.m. read: "Patient given third dose slow IV push. IV intact - still receiving fluids. Just given ED Dilaudid IV. Very distressing pain (Pain scale = 7/10". The physician ordered ED Dilaudid IV 1 mg IV once at 12:14 p.m. (note: this is suggestive of a late entry). A nurse's note at 10:33 a.m. read: "Pt given 4th dose of Dilaudid and zolfran-pain still at 7". Regarding any nursing assessments with respect to vital signs after these administrations, there was no documented evidence of such until 12:05 p.m, approximately one and one half hours later. Vital signs at 12:05 p.m. were found to be within normal limits.

The patient arrived on the unit on 12/31/09 at 1:00 p.m.. Physician orders on 12/31/09 at 1:30 p.m. read (in part): "Stable condition . V/S routine. ... Dilaudid 2 MG IV Q 4 hr PRN (Pain)". The last dose of Dilaudid was administered at 3:53 p.m.. There was no subsequent vital sign assessment until 6:19 p.m. approximately two and one half hours later.

A review of facility policy "Pain Management" revealed the following: "Administer ordered pain medications being mindful of hemodynamic stability. Factor the patient's current and trended vital signs into the pain management decision. ... Evaluate and document the effectiveness of pain relief efforts and take progressive action if pain control is inadequate. Both pharmaceutical and non-pharmaceutical intervention efficacy will be reassessed within one hour. ... An unexpected or sudden, severe pain could indicate a serious complication. Evaluate the exact location and nature of the unexpected or sudden, severe pain as well as the patient ' s clinical status and vital signs. Notify the physician immediately".

During an interview with the Risk manager on 2/17/10 at approximately 4:30 p.m. , she stated that it is the facility's expectation that nurse ' s conduct vital signs within a reasonable time frame (one hour) and in accordance with policy after the administration of narcotic medications. She confirmed that there was no evidence in the medical record which demonstrated that this was done. She confirmed the documented times as stated above.