HospitalInspections.org

Based on policy review, closed medical record review, and staff interviews, the Interventional Radiology (IR) nursing staff failed to follow the department assessment policy and the facility pain assessment policy by failing to assess vital signs and pain levels for 1 of 3 patients (patient #16) with nephrostomy tube insertion.
The findings include:
Review of facility Radiology Pre and Post Unit (RPPU) policy #4934 "Scope of Service / Care" revised 02/16 revealed "...ll. SCOPE OF CARE/SERVICE...A RN (registered nurse) assesses patients within 15 minutes of their arrival. Assessment includes blood pressure, heart rate, oxygen saturation levels, and respirations..."
Review of facility policy #NH-PC-PE-502 "Pain Assessment and Management" revealed "...V. PROCEDURE...A. Pain Evaluation: ...patient's self-report of pain is regarded as the most reliable indicator of the existence/intensity of pain...1. Pain Assessment: If the patient presents with pain or develops pain during the course of treatment a comprehensive/initial assessment is completed based on the patient's condition, scope of care and services provided...B. Pain Re-assessments: 1. Re-assessments evaluate for any new onset of pain, a focused assessment of current pain and effectiveness of the pain plan of care associated with interventional therapy...2. Re-assessments occur before and after implementing the treatment plan which may include both pharmacological and non-pharmacological interventions. 3. Re-assessments after a pharmacological intervention occurs within 60 minutes...6. Reassessments occur in an outpatient area as above (#3) or prior to discharge (whichever comes first)...9. Reassessments occur with any outpatient visit (when indicated)...Vll. DEFINITIONS: Pain is: "what the patient says it is and exists when the patient says it does..."
Closed medical record review for Patient # 16 revealed a 65 year old female admitted to Interventional Radiology (IR) as an outpatient on 2/16/16 for insertion of a nephrostomy tube (tube inserted into the kidney to drain urine) as a result of the presence of a 3centimeter (unit of measure) kidney stone.
Review of physician orders revealed the following:
2/16/16 at 10:59 am - dilaudid (pain medication) 0.5mg (milligrams) IV (intravenously) every 10 minutes for pain (for a total of 4 doses)
2/16/16 at 10:59 am - norco (pain medication) 7.5/325mg by mouth once as needed for pain
2/16/16 at 12:39pm - oxybutynin (medication to treat muscle spasms of the bladder) 5mg by mouth once for bladder spasms
Review revealed the patient left the procedure room following the procedure at 1018, and was admitted to the RPPU (Radiology Pre and Post Procedure Unit) for recovery. Review revealed the following nursing documentation:
2/16/16 at 10:39 - "left posterior lower dressing D&I (dry and intact) - used bedpan - approximately 50ml (milliliters) of cherry red uop (urinary output). Currently on the BS (bedside) commode."
2/16/16 at 11:19 - "Voided in bedside commode. Bright red blood noted. Complains of spasms. (MD #1) called with update. New orders given."
2/16/16 at 12:55pm - "continues to have spasms new order recd (received). voided. vss (vital signs stable)."
Pain Score:
2/16/16 at 11:06 am - 8 (on a scale of 0-10 with 0 being no pain and 10 being the worst), location - abdomen
2/16/16 at 11:18am - 8, location - abdomen
Medication administration:
2/16/16 at 11:02 am - dilaudid 0.5 mg IV
2/16/16 at 11:11 am - dilaudid 0.5mg IV
2/16/16 at 12:39 pm - oxybutynin 5mg by mouth
An interview with RN #1 on 02/16/2016 at 1400 revealed "...I did not give more dilaudid because it wasn't helping...I remember going back and forth with (MD #1) and he did not want to give her anything else. He finally ordered the oxybutynin x 1 but refused more pain med and referred her to her nephrologist (kidney specialist)..." The RN further stated "...I don't do a pain scale for spasms..."
Interview conducted with IR Manager and RN #2 on 5/18/16 05/18/2016 at 1415 revealed there were no vital signs documented while the patient was in the RPPU following the procedure, and confirmed the department scope of service policy was not followed. The interview further confirmed that no pain reassessment occurred following the administration of pain medications, and that the pain assessment policy was not followed.
NC00115838, NC00116289, NC00116432, NC00116898