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Based on record review and interview the facility failed to do the pain assessment and re-assessment for one of 30 sample selected patients (Patient 23) when Patient 23 was in the Emergency Department (ED) for abdominal pain and Patient 23's pain was not reassessed after the initial assessment.

This failure had the potential to result in Patient 23 experiencing uncontrolled pain, delayed treatment, increased complications, and reduced satisfaction.

Findings:

A review of Patient 23's History and Physical (H&P), dated 4/14/25, indicated Patient 23 was admitted to the hospital with abdominal pain.

A review of Patient 23's pain flowsheet record indicated, Patient 23's abdominal pain score was six out of 10 on 4/14/25, at "14:11 (2:11 p.m.) in the Emergency Department (ED)," and the next time staff checked Patient 23's pain score on 4/15/25 at "05:35 (5:35 a.m.)," which was15 hours and 24 minutes later, the pain score was four out of 10.

During a consecutive record review and interview on 4/16/25, at 10:00 a.m., with the ED Manager (EDM), Patient 23's pain flow sheet, Medication Administration Record (MAR), and nurses' notes were reviewed. EDM confirmed the pain assessment delay, and stated Patient 23 was not re-assessed for pain and staff did not do any intervention for pain level six out of 10 at that time. Furthermore, EDM stated staff should re-assess patient's pain at least once a shift which is every eight hours.

A review of the facility's policy and procedure (P&P) titled, "Pain Management," dated 12/22/21, indicated " ...Patient Assessment/Reassessment: The registered nurse (RN) will assess the patient's pain level on admission, during the shift assessment ..."

Based on record review and interview, the facility failed to ensure the nursing staff developed and implemented an individualized care plan for one of 30 sample selected patients (Patient 24), when Patient 24 was using Patient-Controlled Analgesia (PCA) and staff did not care plan the PCA.

This failure had the potential to result in patient 24's risk of inadequate pain relief, overdose, unmanaged side effects, prolonged hospital stays, and increased anxiety, all of which can negatively impact recovery and overall health.

Findings:

A review of Patient 24's History and Physical (H&P) dated 4/14/25, indicated Patient 24 was hospitalized for scheduled hysterectomy (a surgical operation to remove all or part of the uterus).

A review of Patient 24's medication order on 4/14/25, indicated, " ... Hydromorphone (a medication used to relieve pain severe enough to require opioid treatment) ... via PCA ..."

A review of Patient 24's Care Plan, dated 4/16/25, indicated staff did not develop any care plan for pain nor PCA.

During an interview on 4/17/25, at 11:15 a.m., with the Medical Surgical Intensive Care Unit Manager (MSICUM), MSICUM stated staff should initiate a care plan for PCA and assess and re-assess the pain frequently. MSICUM stated a care plan for pain control for Patient 24 could help Patient 24 be comfortable and make the recovery from surgery faster.

A review of the facility's policy and procedure (P&P) titled, "Patient Assessment and Reassessment," dated 8/2024, indicated, " ... All members of the care team document the treatment strategies and/or education provided to the patient to meet the plan of care goals, using the appropriate navigator in the EHR. The appropriate care provider will: 1. Select/add the appropriate care plan template(s) based on the patient's diagnosis and assessment findings. Documentation will address the goals of the care plan, interventions will facilitate resolution of problems, and individualized expected end dates by the time of discharge. 2. Add additional goals and interventions as needed throughout the hospitalization. 3. Edit the care plan goal(s) and intervention(s) and individualize them to the patient. Care plan goals and interventions can also be customized using free text. 4. Evaluate the patient and document the goal(s) and intervention(s) implemented ... b. All stable, acute patients will be reassessed as appropriate for their condition during/post treatments and prior to discharge or transfer c. Patients who have continued pain will be reassessed as appropriate ..."

Based on observation and interview and record review, the facility failed to prevent contamination and implement infection prevention plan when:

1. Two of 13 Operation Room (OR) doors were not functioning correctly and were open during the operation.

2. Medication room refrigerator for IV (intravenous) medications was not clean and had unknown white residue.

3. Staff did not maintain aseptic technique during the foley catheter (a type of indwelling urinary catheter (IUC) used to drain urine from the bladder when a person cannot do so naturally) insertion for one of 30 sample selected patients (Patient 24).

These failures had the potential to result in:

1. Increase of risk of infection in OR, Disruption of Airflow Control, Higher Noise Levels, and Temperature and Humidity Changes.

2. Contamination of refrigerator and risk of infection for patients.

3. Urinary tract infections, catheter-associated infections, sepsis, tissue damage, and hospital protocol violations, all which compromise patient safety and increase medical risks.

Findings:

During a review of post operation progress note, "gynecologic oncology progress note" indicated Patient 27 (who had surgery in OR 11) on 4/16/25, at 11:43 a.m., had a total abdominal hysterectomy (surgery to remove the uterus).

During a review of post operation progress note, "HBO (Hepato-Pancreato-Biliary) surgical oncology progress note" indicated Patient 28 (who had surgery in OR 12) on 4/16/25, at 10:27 a.m., had a pancreatectomy (a surgical procedure involving the removal of all or part of the pancreas).

During a concurrent interview and observation of OR on 4/14/25, at 11:10 a.m., with Operation Room Supervisor (ORS), OR room doors numbered 11 and 12 were open during active operation. ORS confirmed the doors were not closed and not functioning correctly and stated the OR staff were aware of the issue.

During an interview on 4/14/25, at 11:20 a.m., with the Clinical Educator (CE), CE observed the OR doors (11 and 12) and stated the OR doors should be closed all the time during the surgery, with minimum traffic because open doors can cause contamination.

During an interview with the Accreditation and Regulatory Supervisor (ARS) on 4/17/25, at 11:50 a.m., ARS stated that facility doesn't have any policy and procedure to keep the OR doors closed during the operation.

During a concurrent observation and interview on 4/15/25, at 9:45 a.m., in medication room at unit 5A (Tele/Oncology) with the Registered Nurse (RN)1, there was unidentified white residue inside the refrigerator, and RN 1 stated staff use that refrigerator for storing patient's IV medication.

During an interview on 4/16/25, at 2:30 p.m., with the Pharmacist Manager (PM), PM stated part of pharmacy scope is to keep the medication refrigerators clean. When the pharmacist or technician checks the medication rooms, they should check the medication refrigerators and clean them. PM stated the nurses can report to the pharmacy if the refrigerators need to be cleaned. Furthermore, PM stated the facility does not have a specific policy and procedure for cleaning the refrigerator and that it is their practice to keep them clean.

During a concurrent observation and interview on 4/14/25, at 1:30 p.m., in the OR with the Operation Room Supervisor (ORS), Registered Nurse (RN)2 prepared the tray for inserting foley catheter for Patient 24: RN 2 took sponges from the sterile tray with right hand and opened the vagina area with left hand and cleaned the contaminated vaginal area with sponges, did not change the gloves, and then held the sterile foley catheter with right hand and inserted it into the bladder with the same contaminated gloves. ORS confirmed the observation and stated that is not the facility's standard of practice for nurses to touch the sterile foley catheter with contaminated gloves. ORS stated RN2 should have changed her gloves in order to touch the sterile foley catheter.

During an interview on 4/16/25, at 9:39 a.m., with the Infection Preventionist (IP), IP stated the OR doors should be kept closed during the operation to minimize the risk of surgical site infection. IP stated the medication refrigerators should be kept clean to prevent infection, and furthermore stated nurses should change their gloves between contaminated and sterile areas of care.

A review of the facility's policy and procedure (Mosby) titled, "Urinary catheter: Indwelling insertion (female)" undated, indicated, " ...6. Wash the perinea! area with soap and water, locate the urinary meatus, and dry the area. Have an assistant hold an alternative light source to illuminate the perineum as needed. Rationale: Washing minimizes contamination in the area before catheter insertion. An alternative light source is helpful because seeing the urinary meatus of a female patient may be difficult because of the patient's distinct anatomy.7. Discard used supplies, remove gloves, and clean hands ... The dominant gloved hand remains sterile. Cleaning follows the principles of medical asepsis and reduces the number of microorganisms at the urethral meatus, decreasing the likelihood that flora on the skin is introduced into the urethra or bladder. If the labia are allowed to close during cleaning, the cleaning procedure must be repeated because the area is contaminated. 15. With the sterile dominant hand, pick up the catheter. Hold the distal end of the catheter loosely coiled in the palm of the dominant hand ..."