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This Condition of Participation is not met based on 1) Two of twenty patient records reviewed, staff interview, and medical record review, the facility failed to provide patient rights in regard to care in a safe setting for Patients #3 and #14. The facility failed to provide and document complete nursing assessments for pain, system assessments for a post operative cardiac patient and skin assessments in the groin area where the patient identified the pain stating "electrical shocks up and down my leg all night long."; The facility also failed to provide nursing assessments as outlined in the facility Policy and Procedure Manual (Policy # 118 and 428).; The facility failed to intervene with a patient who was combative and extubated herself while in restraints. 2) Eight of twenty patient records reviewed, patient and staff interviews and facility records reviewed, the facility failed to provide appropriate nursing services to provide for safety and to meet the needs of Patients #3, #4, #5, #6, #7, #14, #17, #18, and #19. Documentation in patient records did not meet the standard of care for nursing services. The facility failed to assess patient complaints of pain and re-assess patients when interventions were given to ensure the interventions provided were effective and appropriate.

These failures present a substantial probability of adversely affecting all patients' health, safety and wellbeing.

Refer to A-0144 for additional information.

Based on two of twenty patient records reviewed, staff interview, and medical record review, the facility failed to provide patient rights in regard to care in a safe setting for Patients #3 and #14.

The findings include:

1. A medical record review for Patient #3 was conducted on 10/26/2010 at 1:00 p.m. The medical record review revealed the facility did not provide the patient with nursing assessments regarding newly reported pain symptoms on 10/19/2010 during the 7 p.m. - 7 a.m. shift. The patient was in the Intensive Care Unit (ICU) post a surgical implant of a cardiac pacer device (assists to regulate the heart rhythm). The patient record reveals reports of pain initiated at 2:00 a.m. The nurse assigned to the patient failed to provide and document complete nursing assessments for pain, system assessments for cardiac post operative Patient #3 and skin assessments in the groin area where the patient identified the pain. The facility also failed to provide nursing assessments as outlined in the facility Policy and Procedure Manual (Policy # 118 and 428).

Medical record review included the following findings: An interview was conducted with Patient #3 on 10/26/10 at 11:45 a.m. in his hospital room. He stated he complained to the night nurse he was having "electrical shocks up and down my leg all night long." He told his nurse about this pain throughout the night. The nurse told him she would call the doctor to order Morphine. He told the nurse to put the light on in his room and to look at his leg and the nurse told him it wouldn't be necessary. The surveyor asked Patient #3 if the Morphine helped his pain and he said no. He was in pain all night, describing his pain as radiating up and down his left leg. He stated once a different nurse saw the ants that were causing his pain (at the time he didn't know he had ants in his bed) he has been getting excellent care.
A medical record review was conducted on 10/26/2010 at 1:00 p.m. with the Nurse Director and Nurse Manager of the telemetry (cardiac monitoring floor). The medical records are maintained in written and electronic form and require facility staff assistance for review. The medical record was reviewed for nursing pain management evaluation, intervention and response as well as for generalized nursing management of systems including skin.

The following was revealed: Medical Record review for pain assessment/evaluation and intervention:
Patient #3: Pain Evaluation 10/18/2010 7:00 p.m. - 10/19/2010 7:00 a.m.
Occurred: 10/19/2010 Time 0000 (Midnight) By: (Insert initials and name of staff nurse.)Recorded: .10/19/2010 Time 0053 (12:53 a.m.) By: (Insert initials and name of staff nurse.) Pain Evaluation Type: Re-evaluationPain score: 0Pain Scale Used: Numbers 0-10Patient Goal for Pain: 0Location: (This is blank-no staff entry.)Onset: (This is blank-no staff entry.)Intensity: (This is blank-no staff entry.)
Character: (This is blank-no staff entry.)Radiation: (This is blank-no staff entry.)Associated symptoms: (This is blank-no staff entry.)Exacerbating Factors: (This is blank-no staff entry.)
Treatment: (This is blank-no staff entry.)
Comment: (This is blank-no staff entry.)Occurred: 10/19/2010 Time 0200 (2:00 a.m.) By: (Insert initials and name of staff nurse.)Recorded: 10/19/2010 Time 0532 (5:32 a.m.) By: (Insert initials and name of staff nurse.)
Pain Evaluation Type: Evaluation (Pain management review.)Pain score: 5 Pain Scale Used: Numbers 0-1- (on a zero (0) - 10 scale)Patient Goal for Pain: 0Location: All OverLevel of Sedation: Coop/Oriented/Tranquil (Cooperative/Oriented/Tranquil)
Onset: About an hour ago (1:00 a.m.)Intensity: Mildly ModerateCharacter: Pinpricks down LEG/SCROT (Leg and scrotum)Radiation: Pinpricks down L (left) LEG/SCROTAL areaAssociated symptoms: (This is blank-no staff entry.)Exacerbating Factors: (This is blank-no staff entry.)
Treatment: (This is blank-no staff entry.)
Comment: (This is blank-no staff entry.)Occurred: 10/19/2010 Time 0400 (4:00 a.m.) By: (Insert initials and name of staff nurse.)Recorded: 10/19/2010 Time 0053 (5:32 a.m.) By: (Insert initials and name of staff nurse.) Pain Evaluation Type: Re-evaluationPain score: (This is blank- no staff entry.)Pain Schlaer Used: (This is blank-no staff entry.)Location: (This is blank-no staff entry.)Patient Goal for Pain: (This is blank-no staff entry.)Level of sedation: COOP/Oriented/TranquilOnset: (This is blank-no staff entry.)Intensity: (This is blank-no staff entry.)Character: (This is blank-no staff entry.)Radiation: (This is blank-no staff entry.)Associated symptoms: (This is blank-no staff entry.)Exacerbating Factors: (This is blank-no staff entry.)
Treatment: (This is blank-no staff entry.)
Comment: (This is blank-no staff entry.)
Nursing Entries on the Medication Administration Record (MAR): 10/18/2010 7:00 p.m. - 10/19/2010 7:a.m. Contains but not limited to:Oxycodone HCL/Acetaminophen (Percocet 5/325 tablet)The following doses were documented as administered:10/18/2010: Time: 1703 (5:03 p.m.) 2 unit dose tablets.10/18/2010: Time: 2104: (9:04 p.m.) 2 unit dose tablets.10/19/2010: Time: 0509 (5:09 a.m.) 2 unit dose tablets.
Morphine Sulfate (Morphine 2MG/ML syringe= Morphine 2 milligrams per milliliter in syringe).
10/19/2010: Time: 0631 (6:31 a.m.) 1 mg Intraven (Intravenous) Administered: NOW.An interview with the Nursing Director was conducted after the pain evaluation and intervention was reviewed. The Nursing Director explained the expectation of the facility staff nurse is to evaluate for pain as described for the unit where patient is receiving care. The nurse is to document the pain evaluation and the re-evaluation of pain assessment results on the pain management screen in the electronic medical record (EMR). This is to include the information of the type of pain, where it is located and the interventions provided to the patient. The findings of Medication Administration Record (MAR) and the pain evaluations and re-evaluations were reviewed. The director was asked to explain the re-evaluation dated 10/19/2010 at midnight. The Nursing Director stated, "This is a re-evaluation of a pain identification. This would indicate a previous pain evaluation." The Director and the Manager of the floor could not explain the administration of pain medications as documented on the MAR for the pain medications administered at 1703, 2104, 0509, and 0631 (5:03 p.m., 9:04 p.m., 5:09 a.m., and 6:31 a.m.). The Nurse Director stated, "The expectation is the nurse will document the pain finding, the pain intervention and the re-evaluation of pain medication or intervention." When asked to verify the lack of evaluation, re-evaluation and the alignment of the medication administration, the Nurse Director stated, "I cannot explain why this occurred." The Nurse Director was asked about the re-evaluation of pain at midnight the Nurse Director stated, "I cannot say for sure and cannot speak for the nurse in the ICU (Intensive Care Unit), but this re-evaluation may be from the medication given at around 9:00 p.m." The Nurse Director could not explain the medications administered without assessment or follow-up assessment stating, "I cannot answer that, maybe it would be best to speak with the Director of the ICU. The Nurse Director was interviewed regarding the assessment and evaluation of the condition of the skin. The Nurse Director stated, "This would be found in the nursing notes and the shift evaluation. The nursing notes reveal the last entry on 10/18/2010 occurring at 1552 (3:52 p.m.) and recorded on 1557 (3:57 p.m.). The next nursing note entry was dated 10/19/2010 occurring at 0730 (7:30 a.m.) and recorded at 0930 (9:30 a.m.). This note states as follows: "Upon first round PT (patient) was C/O (complaining of) LT (left) hip and scrotal pain. While doing a safety check found PT to have lot of ants on patient and linens. PT was assisted OOB (Out of Bed) to chair. AM (Morning) care completed. Charge Nurse notified. Will transfer patient to a different room (insert room #). Plant OP (Operations) notified. Dr. Khan made aware PT had developed a raised rash on hip, scrotum, and LT leg. After bath PT stated he's feeling much better. Skin barrier CRM (Cream) applied to LT groin/leg and scrotum to ease skin rash. Will continue to monitor."
The 7 a.m. - 7 p.m. ICU nurse shift evaluation dated 10/19/2010 at 0730 (7:30 a.m.) documents a skin assessment including (not limited to) incision, bruises, pressure ulcer (Gluteal fold) and redness in the scrotum/Lt leg and Hip, tissue evaluation: Red and painful, color is red, without drainage. The assessment by the 7 a.m. - 7 p.m. nurse receiving the patient after the room change documents a skin assessment including (not limited to) incision bruises, and pressure ulcer (gluteal fold) and vesicles Left Thigh /Hip, scattered red, one white vesicle Left inner thigh. The Nurse Director of the telemetry floor could not explain the 7 p.m. - 7 a.m. absence of skin assessment documentation during the identification of pain in the left leg and scrotal area at 2:00 a.m. The Nursing Director also could not speak to the lack of pain intervention after the patient c/o pain at 2:00 a.m. The Nurse Director stated, "This (referring to the copies of the MAR, nursing notes and pain evaluations) is the documentation in the record." A telephone interview was conducted with the 7 a.m. - 7 p.m. nurse receiving Patient #3 on the morning of 10/19/2010. The interview was conducted at 4:55 p.m. through 5:10 p.m. on 10/27/2010. The receiving staff nurse stated the 7 p.m. - 7 a.m. (night shift) nurse was busy with the oncoming day shift nurse (giving report on another patient). The receiving day shift nurse went to Patient's #3 bedside to initiate the safety check assessment. The nurse remarked the patient stated he "c/o pain all night." The nurse commented the patient's pain was located in the groin, left leg and scrotum. The nurse continued by stating the skin check of the area revealed the patient had "ants all over his legs, groin area, on his penis and scrotal area." The nurse commented the patient stated he was administered pain medications during the night shift. On 10/27/10 at 7:30 a.m. an interview was conducted with the nurse who was assigned to Patient #3 on 10/19/10 from 0000 to 0700. She stated Patient #3 was alert and oriented on 10/19/10. She stated the patient complained of "pin pricks" as pain on his leg and scrotum area. In her experience with patients who had a pace maker put in (AICD); this would give the patient an electrical shock feeling. The patient asked to put the light on because he needed to use the bed pan. She did not put the light on but turned the patient but went to his right side and turned him to his left to place the bed pan underneath him. At that time she saw graham cracker crumbs in his bed and wiped them up. She did not see any ants. She said this was approximately "3:30ish." He told her he did not need any pain medication. At 5:00 a.m. she gave Patient #3 Percocet because he was complaining of "pin pricks." At 6:00 a.m. she went back to Patient #3 to assess his pain and he told her his pain did not get any better. At that time Morphine was given. She did not re-assess his pain after the Morphine was given. At shift change she did a "pass me safely" session with the nurse who was assigned Patient #3 for the day shift (7:00 a.m. to 7:00 p.m.) on 10/19/10. This was approximately 7:30 a.m. At that time the day shift nurse noticed the ants on Patient #3. The two nurses assisted Patient #3 out of the bed, cleaned him up and moved him to another room. She did not notice any ants throughout the night in his room. When asked if she turned the light on at any time during Patient #3's care she said she did not turn the light on. She stated she would be able to see ants in his room with the lights off.

On 10/27/2010, an interview with the Director of the Intensive Care Unit was conducted at 1:00 p.m. The Director was informed of the pain evaluation, pain interventions the MAR documentation, and the skin assessments. The Director commented the medical record may have additional documentation in the ADL (Activity of Daily Living) screen. The Director returned with additional documentation which included an ADL assist document. This was dated 10/19/2010 as occurring at midnight and recorded at 12:52 a.m. This document indicates there was an assist for repositioning and for a set up for a snack.
An ADL Assistance document dated 10/19/2010 occurring at 2:00 a.m. and recorded at 5:30 a.m. indicated the patient was turned to the left side with assistance and was placed on the bed pan with assistance. Another ADL Assistance document occurring at 2:00 a.m. and recorded at 5:30 a.m. indicated the patient was repositioned to right side, then to back with assistance and assisted with the bedpan. This document also indicates there was no change of linen, bed clothes, oral care, or personal hygiene provided. When asked about the assessment findings including the ADL Assistance documents the Nurse Director stated the evaluation of the above findings during the survey did offer concerns regarding the care and assessments provided for this patient.
2. The facility records for Patient # 14 were reviewed on 10/27/2010 at 9:40 a.m. with the Nurse Director and the Clinical Supervisor revealed this patient was in the Intensive Care Unit (ICU) post admission for near fainting episodes and possible Coronary Artery Disease. The medical records reveal the patient is intubated (tube into airway providing a set number of respirations with set percentage of oxygen) and receiving intravenous (IV) pain medication as continual infusion. The following are documented pain evaluations for this patient:Occurred: 10/19/2010 Time 2000 (8:00 p.m.) By: (Insert initials and name of staff nurse.)Recorded: 10/19/2010 Time 0053 (9:08 p.m.) By: (Insert initials and name of staff nurse.) Pain Evaluation Type: EvaluationPain score: 8Pain Scale Used: Numbers 0-10Patient Goal for Pain: 0Location: Back Level of Sedation: Anxious and AgitatedOnset: AcuteIntensity: Mildly Moderate
Character: AchyRadiation: BackAssociated symptoms: INCR HR (Increased Heart rate)Exacerbating Factors: (This is blank-no staff entry.)
Treatment: (This is blank-no staff entry.)
Comment: (This is blank-no staff entry.)The medical record reveals the patient did not receive additional pain medication for this pain evaluation. The medical record did not contain documentation of other non-pharmacological interventions at the time the pain was identified and evaluated. The re-evaluation of pain occurred at 2209 (10:09 p.m.) and recorded at 2210 (10:10 p.m.) revealed a reduction in the pain score to a score of 5 (out of a 0-10 pain scale). The re-evaluation of the pain did not include comments or nursing notes indicating the nursing interventions which accomplished the decrease in pain score level.

On 10/19/2010, the documentation reveals a Respiratory Therapy note entry. This evaluation occurred at 0400 (4:00 a.m.) and was recorded at 0507 (5:07 a.m.). The document states "PT (patient) self extubated (patient pulled out the breathing tube) placed on Hi flow nasal cannula per Dr.___ (physician name) PT tolerating well. Will continue to monitor. A Pain Evaluation completed by a different nurse reveals the patient Fentanyl drip off (pain and sedation IV infusion).
At 0518 (5:18 a.m.) the assigned nurse completes a nursing note stating, "Went in to PT's room for hourly check. Pt had extubated self even though restrained. Called for help as PT combative with this nurse and has been throughout the night."
The Nurse Director was asked if the medical record contained additional notes from the assigned nurse. The Nurse Director stated, "This is the documentation we have." A review of the ICU flow sheet documentation was conducted. The flow sheet did not contain assessment of the patient's respiratory rate, breathing effort, lung sounds, or respiratory status. The 0400 (4:00 a.m.) entry on the flow sheet includes the heart rate at 96, and a respiratory rate of 27. The Nurse Director stated the Respiratory Therapist notes indicate the patient is tolerating the hi flow oxygen via nasal cannula as "well" and a 4:20 a.m. blood gas reveals an oxygen saturation at 93.9. The facility "Shift Evaluation" completed at 0800 (8:00 a.m.) by the 7 a.m. - 7 p.m. nurse reveals the patient is intubated with lung sounds diminished in all fields with a oxygen saturation at 95%. At this time the previous documentation reveals the patient had self extubated and the patient was receiving oxygen via a cannula (two small tubes inserted approximately 1/4 inch into each nostril). The 7 p.m. - 7 a.m. nurse did not provide an updated shift evaluation outline the continued agitated behaviors, the extubation of the breathing tube, nor to the response to the treatment of the oxygen by nasal cannula. The Respiratory Therapist Ventilator Flowsheet entry at 4:10 a.m. states: PT self extubated Dr ___ (physician name) in room shortly after placed on HFNC (Hi Flow Nasal Cannula). An interview with the Nursing Director for the ICU on 10/27/2010 regarding the assessment and interventions conducted on the 7 p.m. - 7 a.m. shift was conducted at 1:30 p.m. The ICU Director could not comment to the survey findings regarding Patient #14 by commenting the Risk Management was conducting an investigation and Patient #14 medical records had not yet been reviewed.

This Condition of Participation is not in compliance based on eight of twenty patient records reviewed, patient and staff interviews and facility records reviewed, the facility failed to provide appropriate nursing services to meet the needs of Patients #3, #4, #5, #6, #7, #14, #17, #18, and #19. Documentation in patient records did not meet the standard of care for nursing services. The facility failed to assess patient complaints of pain and re-assess patients when interventions were given to ensure the interventions for pain were effective and appropriate.

See A-0395 for more detailed information.

Based on eight of twenty patient records reviewed, patient and staff interviews, and facility records reviewed, the facility failed to provide patient care when identified by the patient and identified by nursing staff. The facility did not ensure nursing care was appropriate and effective.

The findings include:

1. An interview was conducted with Patient #3 on 10/26/10 at 11:45 a.m. in his hospital room. He stated he complained to the night nurse he was having "electrical shocks up and down my leg all night long." He told his nurse about this pain throughout the night. The nurse told him she would call the doctor to order Morphine. He told the nurse to put the light on in his room and to look at his leg and the nurse told him it wouldn't be necessary. The surveyor asked Patient #3 if the Morphine helped his pain and he said no. He was in pain all night, describing his pain as radiating up and down his left leg. He stated that once shift changed and a different nurse came on duty she Immediately saw the ants that were causing his pain (at the time he didn't know he had ants in his bed). He feels he was received excellent after the ants were discovered.
A medical record review was conducted on 10/26/2010 at 1:00 p.m. with the Nurse Director and Nurse Manager of the telemetry (cardiac monitoring floor). The medical records are maintained in written and electronic form and require facility staff assistance for review. The medical record was reviewed for nursing pain management evaluation, intervention and response, and for generalized nursing management of systems including skin.

The following was revealed: Medical Record review for pain assessment/evaluation and intervention.
Patient #3: Pain Evaluation 10/18/2010 7:00 p.m. - 10/19/2010 7:00 a.m.
Occurred: 10/19/2010 Time 0000 (Midnight) By: (Insert initials and name of staff nurse.)Recorded: 10/19/2010 Time 0053 (12:53 a.m.) By: (Insert initials and name of staff nurse.) Pain Evaluation Type: Re-evaluationPain score: 0Pain Scale Used: Numbers 0-10Patient Goal for Pain: 0Location: (This is blank-no staff entry.)Onset: (This is blank-no staff entry.)Intensity: (This is blank-no staff entry.)
Character: (This is blank-no staff entry.)Radiation: (This is blank-no staff entry.)Associated symptoms: (This is blank-no staff entry.)Exacerbating Factors: (This is blank-no staff entry.)
Treatment: (This is blank-no staff entry.)
Comment: (This is blank-no staff entry.)Occurred: 10/19/2010 Time 0200 (2:00 a.m.) By: (Insert initials and name of staff nurse.)Recorded: 10/19/2010 Time 0532 (5:32 a.m.) By: (Insert initials and name of staff nurse.)
Pain Evaluation Type: Evaluation (pain management review)Pain score: 5 Pain Scale Used: Numbers 0-1- (on a zero (0)- 10 scale)Patient Goal for Pain: 0Location: All OverLevel of Sedation: Coop/Oriented/Tranquil (Cooperative/Oriented/Tranquil)
Onset: About an hour ago.Intensity: Mildly ModerateCharacter: Pinpricks down LEG/SCROT (Leg and Scrotum).Radiation: Pinpricks down L (left) LEG/SCROTAL area.Associated symptoms: (This is blank-no staff entry.)Exacerbating Factors: (This is blank-no staff entry.)
Treatment: (This is blank-no staff entry.)
Comment: (This is blank-no staff entry.)Occurred: 10/19/2010 Time 0400 (4:00 a.m.) By: (Insert initials and name of staff nurse.)Recorded: 10/19/2010 Time 0053 (5:32 a.m.) By: (Insert initials and name of staff nurse.) Pain Evaluation Type: Re-evaluationPain score: (This is blank- no staff entry.)Pain Schlaer Used: (This is blank-no staff entry.)Location: (This is blank-no staff entry.)Patient Goal for Pain: (This is blank-no staff entry.)Level of sedation: COOP/Oriented/TranquilOnset: (This is blank-no staff entry.)Intensity: (This is blank-no staff entry.)Character: (This is blank-no staff entry.)Radiation: (This is blank-no staff entry.)Associated symptoms: (This is blank-no staff entry.)Exacerbating Factors: (This is blank-no staff entry.)
Treatment: (This is blank-no staff entry.)
Comment: (This is blank-no staff entry.)
Nursing Entries on the Medication Administration Record (MAR): 10/18/2010 7:00 p.m.-10/19/2010 700:a.m. Contains but not limited to:Oxycodone HCL/Acetaminophen (Percocet 5/325 tablet)The following doses were documented as administered:10/18/2010: Time: 1703 (5:03 p.m.) 2 unit dose tablets.10/18/2010: Time: 2104: (9:04 p.m.) 2 unit dose tablets.10/19/2010: Time: 0509 (5:09 a.m.) 2 unit dose tablets.
Morphine Sulfate (Morphine 2MG/ML syringe= Morphine 2 milligrams per milliliter in syringe).
10/19/2010: Time: 0631 (6:31 a.m.) 1 mg Intraven (Intravenous) Administered: "NOW."An interview with the Nursing Director was conducted after the pain evaluation and intervention was reviewed. The Nursing Director explained the expectation of the facility staff nurse is to evaluate for pain as described, per unit policy. The nurse is to document the pain evaluation and the re-evaluation of pain assessment results on the pain management screen in the electronic medical record (EMR). This is to include the information of the type of pain, where it is located and the interventions provided to the patient. The MAR and the pain evaluations and re-evaluations were reviewed.
The director was asked to explain the re-evaluation dated 10/19/2010 at midnight. The nursing director stated "This is a re-evaluation of pain identification. This would indicate a previous pain evaluation."
The Director and the Manager of the floor could not explain the administration of pain medications as documented on the MAR administered at 1703, 2104, 0509, and 0631 (5:03 p.m., 9:04 p.m., 5:09 a.m. and 6:31 a.m.). The Nurse Director stated, "The expectation is the nurse will document the pain finding, the pain intervention and the re-evaluation of pain medication or intervention." When asked to verify the lack of evaluation, re-evaluation and the alignment of the medication administration, the Nurse Director stated, "I cannot explain why this occurred." The Nurse Director was asked about the re-evaluation of pain at midnight and she stated, "I cannot say for sure and cannot speak for the nurse in the ICU (Intensive care unit), but this re-evaluation may be from the medication given at around 9:00 p.m."
The Nurse Director could not explain the medications administered without assessment or follow-up assessment stating, "I cannot answer that, maybe it would be best to speak with the Director of the ICU."The Nurse Director was interviewed regarding the assessment and evaluation of the condition of the skin. She stated, "This would be found in the nursing notes and the shift evaluation. The nursing notes reveal the last entry on 10/18/2010 occurring at 1552 (3:52 p.m.) and recorded on 1557 (3:57 p.m.). The next nursing note entry was dated 10/19/2010 occurring at 0730 (7:30 a.m.) and recorded at 0930 (9:30 a.m.). This note states as follows: "Upon first round PT (patient) was C/O (complaining of) LT (left) hip and scrotal pain. While doing a safety check found PT to have lot of ants on patient and linens. PT was assisted OOB (Out of Bed) to chair. AM (Morning) care completed. Charge Nurse notified. Will transfer patient to a different room (insert room #). Plant OP (Operations) notified. Dr. Khan made aware PT had developed a raised rash on hip, scrotum, and LT leg. After bath PT stated he's feeling much better. Skin barrier CRM (Cream) applied to LT groin/leg and scrotum to ease skin rash. Will continue to monitor."
The 7 a.m. - 7 p.m. ICU nurse shift evaluation dated 10/19/2010 at 0730 (7:30 a.m.) documents a skin assessment including (not limited to) incision, bruises, pressure ulcer (Gluteal fold) and redness in the scrotum/Lt leg and Hip, tissue evaluation: Red and painful, color is red, without drainage. The assessment by the 7 a.m. - 7 p.m. nurse receiving the patient after the room change documents a skin assessment including (not limited to) incision bruises, and pressure ulcer (gluteal fold) and vesicles Left Thigh /Hip, scattered red, one white vesicle left inner thigh. The Nurse Director of the telemetry floor could not explain the 7 p.m. - 7 a.m. absence of skin assessment documentation related to complaints of pain in the left leg and scrotal area at 2:00 p.m. The Nursing Director also could not speak to the lack of pain intervention after the patient complaint of (c/o) pain at 2:00 a.m. The Nurse Director stated, "This (referring to the copies of the MAR, nursing notes and pain evaluations) is the documentation we have in the medical record." A telephone interview was conducted with the 7 a.m. - 7 p.m. nurse receiving Patient #3 on the morning of 10/19/2010. The interview was conducted at 4:55 p.m. through 5:10 p.m. The receiving staff nurse stated the 7 p.m. - 7 a.m. (night shift) nurse was busy with the oncoming day shift nurse (giving report on another patient). The receiving day shift nurse went to the Patient's #3 bedside to initiate the safety check assessment. The nurse remarked the patient stated he "c/o pain all night." The nurse commented the patient's pain was located in the groin, left leg and scrotum. The nurse continued by stating the skin check of the area revealed the patient had "ants all over his legs, groin area, on his penis and scrotal area." The nurse commented the patient stated he was administered pain medications during the night shift. On 10/27/10 at 7:30 a.m. an interview was conducted with the nurse who was assigned to Patient #3 on 10/19/10 from 000 to 0700. She stated Patient #3 was alert and oriented on 10/19/10. She stated the patient complained of "pin pricks" as pain on his leg and scrotum area. In her experience with patients who had a pace maker put in (AICD); this would give the patient an electrical shock feeling. The patient asked her to put the light on and put him on the bed pan. She did not put the light on but turned the patient but went to his right side and turned him to his left to place the bed pan underneath him. At that time she saw graham cracker crumbs in his bed and wiped them up. She did not see any ants. She said this was approximately "3:30ish." He told her he did not need any pain medication. At 5:00 a.m. she gave Patient #3 Percocet because he was complaining of "pin pricks." At 6:00 a.m. she went back to Patient #3 to assess his pain and he told her his pain did not get any better. At that time Morphine was given. She did not re-assess his pain after the Morphine was given. At shift change she did a "pass me safely" session with the nurse who was assigned Patient #3 for the day shift (7:00 a.m. to 7:00 p.m.) on 10/19/10. This was approximately 7:30 a.m. At that time the day shift nurse noticed the ants on Patient #3. The two nurses assisted Patient #3 out of the bed, cleaned him up and moved him to another room. She did not notice any ants throughout the night in his room. When asked if she turned the light on at any time during Patient #3's care she said she did not turn the light on. She would be able to see ants in his room with the lights off.

On 10/27/2010, an interview with the Director of the Intensive Care Unit was conducted at 1:00 p.m. The Director was informed of the pain evaluation, pain interventions, the MAR documentation and the skin assessments. The Director commented the medical record may have additional documentation in the ADL (Activity of Daily Living) screen. The Director returned with additional documentation which included an ADL assist document. This was dated 10/19/2010 as occurring at midnight and recorded at 12:52 a.m. This document indicates there was an assist for repositioning and for a set up for a snack.
An ADL Assistance document dated 10/19/2010 occurring at 2:00 a.m. and recorded at 5:30 a.m. indicated the patient was turned to the left side with assistance and was placed on the bed pan with assistance. Another ADL Assistance document occurring at 2:00 a.m. and recorded at 5:30 a.m. indicated the patient was repositioned to right side, then to back with assistance and assisted with the bedpan. This document also indicates there was no change of linen, bed clothes, oral care, or personal hygiene provided. When asked about the assessment findings including the ADL Assistance the Nurse Director stated the evaluation of the above findings during the survey did offer concerns regarding the care and assessments provided for this patient.
2. The facility records for Patient # 14 were reviewed on 10/27/2010 at 9:40 a.m. with the Nurse Director and the Clinical Supervisor revealed this patient was in the Intensive Care Unit (ICU) post admission for near fainting episodes and possible Coronary Artery Disease. The medical records reveal the patient is intubated (tube into airway providing a set number of respirations with set percentage of oxygen) and receiving intravenous (IV) pain medication as continual infusion. The following are documented pain evaluations for this patient:Occurred: 10/19/2010 Time 2000 (8:00 p.m.) By: (Insert initials and name of staff nurse.)Recorded: 10/19/2010 Time 0053 (9:08 p.m.) By: (Insert initials and name of staff nurse.) Pain Evaluation Type: EvaluationPain score: 8Pain Scale Used: Numbers 0-10Patient Goal for Pain: 0Location: Back Level of Sedation: Anxious and AgitatedOnset: AcuteIntensity: Mildly Moderate
Character: AchyRadiation: BackAssociated symptoms: INCR HR (Increased Heart rate)Exacerbating Factors: (This is blank-no staff entry.)
Treatment: (This is blank-no staff entry.)
Comment: (This is blank-no staff entry.)The medical record reveals the patient did not receive additional pain medication for this pain evaluation. The medical record did not contain documentation of other non-pharmacological interventions at the time the pain was identified and evaluated. The re-evaluation of pain occurred at 2209 (10:09 p.m.) and recorded at 2210 (10:10 p.m.) revealed a reduction in the pain score to a score of 5 (out of a 0-10 pain scale). The re-evaluation of the pain did not include comments or nursing notes indicating the nursing interventions which accomplished the decrease in pain score level.

On 10/19/2010, the documentation reveals a Respiratory Therapy note entry. This evaluation occurred at 0400 (4:00 a.m.) and was recorded at 0507 (5:07 a.m.). The document states "PT (patient) self extubated (patient pulled out the breathing tube) placed on Hi flow nasal cannula per Dr.___ (physician name) PT tolerating well. Will continue to monitor. A Pain Evaluation was completed by a different nurse reveals the patient's Fentanyl drip off (pain and sedation IV infusion).
At 0518 (5:18 a.m.) the assigned nurse completes a nursing note stating, "Went in to PT's room for hourly check. Pt had extubated self even though restrained. Called for help as PT combative with this nurse and has been throughout the night."
The Nurse Director was asked if the medical record contained additional notes from the assigned nurse. The Nurse Director stated, "This is the documentation we have." A review of the ICU flow sheet documentation was conducted. The flow sheet did not contain assessment of the patient's respiratory rate, breathing effort, lung sounds, or respiratory status. The 0400 (4:00 a.m.) entry on the flow sheet includes the heart rate at 96, and a respiratory rate of 27. The Nurse Director stated the Respiratory Therapist notes indicate the patient is tolerating the hi flow oxygen via nasal cannula as "well" and a 4:20 a.m. blood gas reveals an oxygen saturation at 93.9.

The 7 p.m. - 7 a.m. nurse did not provide an updated shift evaluation outlining the continued agitated behaviors, the extubation of the breathing tube, nor to the response to the treatment of the oxygen by nasal cannula. The Respiratory Therapist Ventilator Flowsheet entry at 4:10 a.m. states: PT self extubated Dr ___ (physician name) in room shortly after placed on (Hi Flow Nasal Cannula).
The facility "Shift Evaluation" completed at 0800 (8:00 a.m.) by the 7 a.m. - 7 p.m. nurse reveals the patient is intubated with lung sounds diminished in all fields with a oxygen saturation at 95%. At this time the previous documentation reveals the patient had self extubated and the patient was receiving oxygen via a cannula (two small tubes inserted approximately 1/4 inch into each nostril).

During an interview with the ICU Director on 10/27/10 at 1:15 p.m., she had stated she had reviewed all the clinical records involving the 7 p.m - 7 a.m. nurse in preperation for her meeting with her on 10/28/10. She also indicated the nurse was new to the system, having been hired on 8/9/10 and was still in orientation, being supervised. Regarding the assessment and interventions by this nurse conducted on the 7 p.m. - 7 a.m. shift, she could not comment to the survey findings regarding Patient #14 by commenting the Risk Management was conducting an investigation and Patient #14's medical record had not yet been reviewed.

The ICU Director and the Risk Manager confirmed that on the 7 p.m - 7 a.m shift on 10/18-10/19/10, this nurse was only assigned these two patients (#3 and #14). The ICU director confirmed she failed to review the chart of the other patient (Patient # 14) assigned to this nurse that night.

3. A review of Patient #19's medical record on 10/27/10 showed on 10/22/10 at 1700 the patient complained of pain at a number 3 on a scale of 1 to 10. The patient also complained at 11:26 a.m. of pain at a number 8 on a scale of 1 to 10. This review was on the pain monitoring form. Further review of this medical record showed there were no interventions made by the nurse when Patient #19 complained of these pains. The nurse's notes, Medication Administration Records, evaluations, re-evaluations and pain management monitoring forms were reviewed, along with several other areas of the patient record reviewed and showed the patient did not receive any interventions concerning these two complaints of pain.

Interview with the nurse on 10/27/10 at 1:45 p.m. stated she was not able to find any documentation the patient received any intervention for these two complainants of pain.

4. A review of Patient #4's medical record on 10/27/10 showed on 10/24/10 at 0800 the patient complained of pain at a 7 on a scale of 1 to 10. A review of the Medication Administration Record (MAR) showed the patient received Fentanyl. On 10/23/10 at 0800 the patient complained of pain and the nurse gave medication and changed the patient's position. However, with these two interventions to relieve Patient #4's pain there was no documentation in her record to show the nurses re-assessed the patient to ensure these interventions relieved her pain.

Interview with the nurse on 10/27/10 at 9:45 a.m. stated she was not able to find anywhere in the patient record where re-assessments occurred. This nurse then asked another nurse from this unit where to find these re-assessments. The nurse told her re-assessments will be found either in the nurse's notes, evaluations, re-evaluations, or the pain monitoring form. These forms were reviewed and there was no documentation of a re-assessment.

5. A review of Patient #5's medical record on 10/27/10 showed on 10/19/10 at 0800 the patient complained of pain at a 7 on a scale of 1 to 10. The patient was given Percocet. On 10/23/10 at 0309 the patient complained of pain at a 3 and the patient was given Morphine. On 10/23/10 at 0907 (9:07 a.m.) the patient complained of pain at a 6 and was given Percocet. Further review of Patient #5's medical record showed there were no re-assessments of the patient for the interventions used to relieve the pain.

An interview was conducted with a nurse on the unit at 10:45 a.m. She stated if a patient complains of pain and is given an intervention for this pain an assessment within the first hour should be done. This assessment should be documented on the pain evaluation form or the re-evaluation sheet. Another review of these two forms was completed and there was no documentation of the re-assessments.

6. A review of Patient #6's medical record on 10/27/10 showed on 10/20/10 at 2010 the patient complained of pain. A review of the MAR showed pain medication was given. Further review of this record showed there was no documentation of a re-assessment on Patient #6 to evaluate if the medication intervention was successful.

7. A review of Patient #7's medical record on 10/27/10 showed on 10/27/10 at 0000 (12:00 a.m.) the patient complained of pain at an 8 on a scale on 1 to 10. He was given medication and repositioned. The patient complained of pain at 0445 at an 8. He was given medication. Further review of this medical record showed there was no documentation of re-assessments completed once the patient was given medications for his pain either time.

Interview with the nurse at 11:00 a.m., who was reviewing the chart, stated she was not able to find the documentation of the re-assessments for these two interventions for pain. She re-iterated she looked in the areas of the patient's medical record where the nurse on this unit would document a pain re-assessments.

8. A review of Patient #18's medical record on 10/27/10 showed on 10/26/10 at 0800 the patient complained of pain at an 8 on a scale of 1 to 10. The patient was given Dilaudid. At 1009 (10:09 a.m.) the patient complained of pain and was given Dilaudid again. Documentation showed the nurse re-assessed the patient's pain at 1200. However, there was no re-assessment of the first intervention of Dilaudid given at 0800.

An interview was conducted with the Unit Nurse at 1:15 p.m. on 10/27/10. She went through Patient #18's medical record and stated she, also, could not find any documentation of a re-assessment done when the patient was given medication for his pain at 0800.

Based on a review of 1 (Patient # 3) of 20 patient records and staff interview, the facility failed to ensure Patient #3's medical record was maintained accurately.

The findings include:

A review of Patient #3's medical record on 10/26/10 showed on 10/19/10 at 0200 (2:00 a.m.) the patient was assisted on the bedpan and complained of "pin pricks." This was documented at 0532 (5:32 a.m.). At 0400 (4:00 a.m.) the nurse re-evaluated Patient #3's pain and assisted the patient with a urinal. The pain evaluation was documented at 0532 and the assistance with the urinal was documented at 0530 (5:30 a.m.).

On 10/27/10 at 7:30 a.m., an interview was conducted with the registered nurse, who documented these events and who was assigned to Patient #3 on 10/19/10 from 000 to 0700 (7:00 a.m.). She stated she documented these two entries but they were not accurate. She stated there was no patient contact at 0200 (2:00 a.m.) and 0400 (4:00 a.m.) for Patient #3. She was asked again about these two entries and she stated the documentation was an error on her part and there was no patient contact.

This Condition of Participation is not met based on 1) Two of twenty patient records reviewed, staff interview, and medical record review, the facility failed to provide patient rights in regard to care in a safe setting for Patients #3 and #14. The facility failed to provide and document complete nursing assessments for pain, system assessments for a post operative cardiac patient and skin assessments in the groin area where the patient identified the pain stating "electrical shocks up and down my leg all night long."; The facility also failed to provide nursing assessments as outlined in the facility Policy and Procedure Manual (Policy # 118 and 428).; The facility failed to intervene with a patient who was combative and extubated herself while in restraints. 2) Eight of twenty patient records reviewed, patient and staff interviews and facility records reviewed, the facility failed to provide appropriate nursing services to provide for safety and to meet the needs of Patients #3, #4, #5, #6, #7, #14, #17, #18, and #19. Documentation in patient records did not meet the standard of care for nursing services. The facility failed to assess patient complaints of pain and re-assess patients when interventions were given to ensure the interventions provided were effective and appropriate.

These failures present a substantial probability of adversely affecting all patients' health, safety and wellbeing.

Refer to A-0144 for additional information.

Based on two of twenty patient records reviewed, staff interview, and medical record review, the facility failed to provide patient rights in regard to care in a safe setting for Patients #3 and #14.

The findings include:

1. A medical record review for Patient #3 was conducted on 10/26/2010 at 1:00 p.m. The medical record review revealed the facility did not provide the patient with nursing assessments regarding newly reported pain symptoms on 10/19/2010 during the 7 p.m. - 7 a.m. shift. The patient was in the Intensive Care Unit (ICU) post a surgical implant of a cardiac pacer device (assists to regulate the heart rhythm). The patient record reveals reports of pain initiated at 2:00 a.m. The nurse assigned to the patient failed to provide and document complete nursing assessments for pain, system assessments for cardiac post operative Patient #3 and skin assessments in the groin area where the patient identified the pain. The facility also failed to provide nursing assessments as outlined in the facility Policy and Procedure Manual (Policy # 118 and 428).

Medical record review included the following findings: An interview was conducted with Patient #3 on 10/26/10 at 11:45 a.m. in his hospital room. He stated he complained to the night nurse he was having "electrical shocks up and down my leg all night long." He told his nurse about this pain throughout the night. The nurse told him she would call the doctor to order Morphine. He told the nurse to put the light on in his room and to look at his leg and the nurse told him it wouldn't be necessary. The surveyor asked Patient #3 if the Morphine helped his pain and he said no. He was in pain all night, describing his pain as radiating up and down his left leg. He stated once a different nurse saw the ants that were causing his pain (at the time he didn't know he had ants in his bed) he has been getting excellent care.
A medical record review was conducted on 10/26/2010 at 1:00 p.m. with the Nurse Director and Nurse Manager of the telemetry (cardiac monitoring floor). The medical records are maintained in written and electronic form and require facility staff assistance for review. The medical record was reviewed for nursing pain management evaluation, intervention and response as well as for generalized nursing management of systems including skin.

The following was revealed: Medical Record review for pain assessment/evaluation and intervention:
Patient #3: Pain Evaluation 10/18/2010 7:00 p.m. - 10/19/2010 7:00 a.m.
Occurred: 10/19/2010 Time 0000 (Midnight) By: (Insert initials and name of staff nurse.)Recorded: .10/19/2010 Time 0053 (12:53 a.m.) By: (Insert initials and name of staff nurse.) Pain Evaluation Type: Re-evaluationPain score: 0Pain Scale Used: Numbers 0-10Patient Goal for Pain: 0Location: (This is blank-no staff entry.)Onset: (This is blank-no staff entry.)Intensity: (This is blank-no staff entry.)
Character: (This is blank-no staff entry.)Radiation: (This is blank-no staff entry.)Associated symptoms: (This is blank-no staff entry.)Exacerbating Factors: (This is blank-no staff entry.)
Treatment: (This is blank-no staff entry.)
Comment: (This is blank-no staff entry.)Occurred: 10/19/2010 Time 0200 (2:00 a.m.) By: (Insert initials and name of staff nurse.)Recorded: 10/19/2010 Time 0532 (5:32 a.m.) By: (Insert initials and name of staff nurse.)
Pain Evaluation Type: Evaluation (Pain management review.)Pain score: 5 Pain Scale Used: Numbers 0-1- (on a zero (0) - 10 scale)Patient Goal for Pain: 0Location: All OverLevel of Sedation: Coop/Oriented/Tranquil (Cooperative/Oriented/Tranquil)
Onset: About an hour ago (1:00 a.m.)Intensity: Mildly ModerateCharacter: Pinpricks down LEG/SCROT (Leg and scrotum)Radiation: Pinpricks down L (left) LEG/SCROTAL areaAssociated symptoms: (This is blank-no staff entry.)Exacerbating Factors: (This is blank-no staff entry.)
Treatment: (This is blank-no staff entry.)
Comment: (This is blank-no staff entry.)Occurred: 10/19/2010 Time 0400 (4:00 a.m.) By: (Insert initials and name of staff nurse.)Recorded: 10/19/2010 Time 0053 (5:32 a.m.) By: (Insert initials and name of staff nurse.) Pain Evaluation Type: Re-evaluationPain score: (This is blank- no staff entry.)Pain Schlaer Used: (This is blank-no staff entry.)Location: (This is blank-no staff entry.)Patient Goal for Pain: (This is blank-no staff entry.)Level of sedation: COOP/Oriented/TranquilOnset: (This is blank-no staff entry.)Intensity: (This is blank-no staff entry.)Character: (This is blank-no staff entry.)Radiation: (This is blank-no staff entry.)Associated symptoms: (This is blank-no staff entry.)Exacerbating Factors: (This is blank-no staff entry.)
Treatment: (This is blank-no staff entry.)
Comment: (This is blank-no staff entry.)
Nursing Entries on the Medication Administration Record (MAR): 10/18/2010 7:00 p.m. - 10/19/2010 7:a.m. Contains but not limited to:Oxycodone HCL/Acetaminophen (Percocet 5/325 tablet)The following doses were documented as administered:10/18/2010: Time: 1703 (5:03 p.m.) 2 unit dose tablets.10/18/2010: Time: 2104: (9:04 p.m.) 2 unit dose tablets.10/19/2010: Time: 0509 (5:09 a.m.) 2 unit dose tablets.
Morphine Sulfate (Morphine 2MG/ML syringe= Morphine 2 milligrams per milliliter in syringe).
10/19/2010: Time: 0631 (6:31 a.m.) 1 mg Intraven (Intravenous) Administered: NOW.An interview with the Nursing Director was conducted after the pain evaluation and intervention was reviewed. The Nursing Director explained the expectation of the facility staff nurse is to evaluate for pain as described for the unit where patient is receiving care. The nurse is to document the pain evaluation and the re-evaluation of pain assessment results on the pain management screen in the electronic medical record (EMR). This is to include the information of the type of pain, where it is located and the interventions provided to the patient. The findings of Medication Administration Record (MAR) and the pain evaluations and re-evaluations were reviewed. The director was asked to explain the re-evaluation dated 10/19/2010 at midnight. The Nursing Director stated, "This is a re-evaluation of a pain identification. This would indicate a previous pain evaluation." The Director and the Manager of the floor could not explain the administration of pain medications as documented on the MAR for the pain medications administered at 1703, 2104, 0509, and 0631 (5:03 p.m., 9:04 p.m., 5:09 a.m., and 6:31 a.m.). The Nurse Director stated, "The expectation is the nurse will document the pain finding, the pain intervention and the re-evaluation of pain medication or intervention." When asked to verify the lack of evaluation, re-evaluation and the alignment of the medication administration, the Nurse Director stated, "I cannot explain why this occurred." The Nurse Director was asked about the re-evaluation of pain at midnight the Nurse Director stated, "I cannot say for sure and cannot speak for the nurse in the ICU (Intensive Care Unit), but this re-evaluation may be from the medication given at around 9:00 p.m." The Nurse Director could not explain the medications administered without assessment or follow-up assessment stating, "I cannot answer that, maybe it would be best to speak with the Director of the ICU. The Nurse Director was interviewed regarding the assessment and evaluation of the condition of the skin. The Nurse Director stated, "This would be found in the nursing notes and the shift evaluation. The nursing notes reveal the last entry on 10/18/2010 occurring at 1552 (3:52 p.m.) and recorded on 1557 (3:57 p.m.). The next nursing note entry was dated 10/19/2010 occurring at 0730 (7:30 a.m.) and recorded at 0930 (9:30 a.m.). This note states as follows: "Upon first round PT (patient) was C/O (complaining of) LT (left) hip and scrotal pain. While doing a safety check found PT to have lot of ants on patient and linens. PT was assisted OOB (Out of Bed) to chair. AM (Morning) care completed. Charge Nurse notified. Will transfer patient to a different room (insert room #). Plant OP (Operations) notified. Dr. Khan made aware PT had developed a raised rash on hip, scrotum, and LT leg. After bath PT stated he's feeling much better. Skin barrier CRM (Cream) applied to LT groin/leg and scrotum to ease skin rash. Will continue to monitor."
The 7 a.m. - 7 p.m. ICU nurse shift evaluation dated 10/19/2010 at 0730 (7:30 a.m.) documents a skin assessment including (not limited to) incision, bruises, pressure ulcer (Gluteal fold) and redness in the scrotum/Lt leg and Hip, tissue evaluation: Red and painful, color is red, without drainage. The assessment by the 7 a.m. - 7 p.m. nurse receiving the patient after the room change documents a skin assessment including (not limited to) incision bruises, and pressure ulcer (gluteal fold) and vesicles Left Thigh /Hip, scattered red, one white vesicle Left inner thigh. The Nurse Director of the telemetry floor could not explain the 7 p.m. - 7 a.m. absence of skin assessment documentation during the identification of pain in the left leg and scrotal area at 2:00 a.m. The Nursing Director also could not speak to the lack of pain intervention after the patient c/o pain at 2:00 a.m. The Nurse Director stated, "This (referring to the copies of the MAR, nursing notes and pain evaluations) is the documentation in the record." A telephone interview was conducted with the 7 a.m. - 7 p.m. nurse receiving Patient #3 on the morning of 10/19/2010. The interview was conducted at 4:55 p.m. through 5:10 p.m. on 10/27/2010. The receiving staff nurse stated the 7 p.m. - 7 a.m. (night shift) nurse was busy with the oncoming day shift nurse (giving report on another patient). The receiving day shift nurse went to Patient's #3 bedside to initiate the safety check assessment. The nurse remarked the patient stated he "c/o pain all night." The nurse commented the patient's pain was located in the groin, left leg and scrotum. The nurse continued by stating the skin check of the area revealed the patient had "ants all over his legs, groin area, on his penis and scrotal area." The nurse commented the patient stated he was administered pain medications during the night shift. On 10/27/10 at 7:30 a.m. an interview was conducted with the nurse who was assigned to Patient #3 on 10/19/10 from 0000 to 0700. She stated Patient #3 was alert and oriented on 10/19/10. She stated the patient complained of "pin pricks" as pain on his leg and scrotum area. In her experience with patients who had a pace maker put in (AICD); this would give the patient an electrical shock feeling. The patient asked to put the light on because he needed to use the bed pan. She did not put the light on but turned the patient but went to his right side and turned him to his left to place the bed pan underneath him. At that time she saw graham cracker crumbs in his bed and wiped them up. She did not see any ants. She said this was approximately "3:30ish." He told her he did not need any pain medication. At 5:00 a.m. she gave Patient #3 Percocet because he was complaining of "pin pricks." At 6:00 a.m. she went back to Patient #3 to assess his pain and he told her his pain did not get any better. At that time Morphine was given. She did not re-assess his pain after the Morphine was given. At shift change she did a "pass me safely" session with the nurse who was assigned Patient #3 for the day shift (7:00 a.m. to 7:00 p.m.) on 10/19/10. This was approximately 7:30 a.m. At that time the day shift nurse noticed the ants on Patient #3. The two nurses assisted Patient #3 out of the bed, cleaned him up and moved him to another room. She did not notice any ants throughout the night in his room. When asked if she turned the light on at any time during Patient #3's care she said she did not turn the light on. She stated she would be able to see ants in his room with the lights off.

On 10/27/2010, an interview with the Director of the Intensive Care Unit was conducted at 1:00 p.m. The Director was informed of the pain evaluation, pain interventions the MAR documentation, and the skin assessments. The Director commented the medical record may have additional documentation in the ADL (Activity of Daily Living) screen. The Director returned with additional documentation which included an ADL assist document. This was dated 10/19/2010 as occurring at midnight and recorded at 12:52 a.m. This document indicates there was an assist for repositioning and for a set up for a snack.
An ADL Assistance document dated 10/19/2010 occurring at 2:00 a.m. and recorded at 5:30 a.m. indicated the patient was turned to the left side with assistance and was placed on the bed pan with assistance. Another ADL Assistance document occurring at 2:00 a.m. and recorded at 5:30 a.m. indicated the patient was repositioned to right side, then to back with assistance and assisted with the bedpan. This document also indicates there was no change of linen, bed clothes, oral care, or personal hygiene provided. When asked about the assessment findings including the ADL Assistance documents the Nurse Director stated the evaluation of the above findings during the survey did offer concerns regarding the care and assessments provided for this patient.
2. The facility records for Patient # 14 were reviewed on 10/27/2010 at 9:40 a.m. with the Nurse Director and the Clinical Supervisor revealed this patient was in the Intensive Care Unit (ICU) post admission for near fainting episodes and possible Coronary Artery Disease. The medical records reveal the patient is intubated (tube into airway providing a set number of respirations with set percentage of oxygen) and receiving intravenous (IV) pain medication as continual infusion. The following are documented pain evaluations for this patient:Occurred: 10/19/2010 Time 2000 (8:00 p.m.) By: (Insert initials and name of staff nurse.)Recorded: 10/19/2010 Time 0053 (9:08 p.m.) By: (Insert initials and name of staff nurse.) Pain Evaluation Type: EvaluationPain score: 8Pain Scale Used: Numbers 0-10Patient Goal for Pain: 0Location: Back Level of Sedation: Anxious and AgitatedOnset: AcuteIntensity: Mildly Moderate
Character: AchyRadiation: BackAssociated symptoms: INCR HR (Increased Heart rate)Exacerbating Factors: (This is blank-no staff entry.)
Treatment: (This is blank-no staff entry.)
Comment: (This is blank-no staff entry.)The medical record reveals the patient did not receive additional pain medication for this pain evaluation. The medical record did not contain documentation of other non-pharmacological interventions at the time the pain was identified and evaluated. The re-evaluation of pain occurred at 2209 (10:09 p.m.) and recorded at 2210 (10:10 p.m.) revealed a reduction in the pain score to a score of 5 (out of a 0-10 pain scale). The re-evaluation of the pain did not include comments or nursing notes indicating the nursing interventions which accomplished the decrease in pain score level.

On 10/19/2010, the documentation reveals a Respiratory Therapy note entry. This evaluation occurred at 0400 (4:00 a.m.) and was recorded at 0507 (5:07 a.m.). The document states "PT (patient) self extubated (patient pulled out the breathing tube) placed on Hi flow nasal cannula per Dr.___ (physician name) PT tolerating well. Will continue to monitor. A Pain Evaluation completed by a different nurse reveals the patient Fentanyl drip off (pain and sedation IV infusion).
At 0518 (5:18 a.m.) the assigned nurse completes a nursing note stating, "Went in to PT's room for hourly check. Pt had extubated self even though restrained. Called for help as PT combative with this nurse and has been throughout the night."
The Nurse Director was asked if the medical record contained additional notes from the assigned nurse. The Nurse Director stated, "This is the documentation we have." A review of the ICU flow sheet documentation was conducted. The flow sheet did not contain assessment of the patient's respiratory rate, breathing effort, lung sounds, or respiratory status. The 0400 (4:00 a.m.) entry on the flow sheet includes the heart rate at 96, and a respiratory rate of 27. The Nurse Director stated the Respiratory Therapist notes indicate the patient is tolerating the hi flow oxygen via nasal cannula as "well" and a 4:20 a.m. blood gas reveals an oxygen saturation at 93.9. The facility "Shift Evaluation" completed at 0800 (8:00 a.m.) by the 7 a.m. - 7 p.m. nurse reveals the patient is intubated with lung sounds diminished in all fields with a oxygen saturation at 95%. At this time the previous documentation reveals the patient had self extubated and the patient was receiving oxygen via a cannula (two small tubes inserted approximately 1/4 inch into each nostril). The 7 p.m. - 7 a.m. nurse did not provide an updated shift evaluation outline the continued agitated behaviors, the extubation of the breathing tube, nor to the response to the treatment of the oxygen by nasal cannula. The Respiratory Therapist Ventilator Flowsheet entry at 4:10 a.m. states: PT self extubated Dr ___ (physician name) in room shortly after placed on HFNC (Hi Flow Nasal Cannula). An interview with the Nursing Director for the ICU on 10/27/2010 regarding the assessment and interventions conducted on the 7 p.m. - 7 a.m. shift was conducted at 1:30 p.m. The ICU Director could not comment to the survey findings regarding Patient #14 by commenting the Risk Management was conducting an investigation and Patient #14 medical records had not yet been reviewed.

This Condition of Participation is not in compliance based on eight of twenty patient records reviewed, patient and staff interviews and facility records reviewed, the facility failed to provide appropriate nursing services to meet the needs of Patients #3, #4, #5, #6, #7, #14, #17, #18, and #19. Documentation in patient records did not meet the standard of care for nursing services. The facility failed to assess patient complaints of pain and re-assess patients when interventions were given to ensure the interventions for pain were effective and appropriate.

See A-0395 for more detailed information.

Based on eight of twenty patient records reviewed, patient and staff interviews, and facility records reviewed, the facility failed to provide patient care when identified by the patient and identified by nursing staff. The facility did not ensure nursing care was appropriate and effective.

The findings include:

1. An interview was conducted with Patient #3 on 10/26/10 at 11:45 a.m. in his hospital room. He stated he complained to the night nurse he was having "electrical shocks up and down my leg all night long." He told his nurse about this pain throughout the night. The nurse told him she would call the doctor to order Morphine. He told the nurse to put the light on in his room and to look at his leg and the nurse told him it wouldn't be necessary. The surveyor asked Patient #3 if the Morphine helped his pain and he said no. He was in pain all night, describing his pain as radiating up and down his left leg. He stated that once shift changed and a different nurse came on duty she Immediately saw the ants that were causing his pain (at the time he didn't know he had ants in his bed). He feels he was received excellent after the ants were discovered.
A medical record review was conducted on 10/26/2010 at 1:00 p.m. with the Nurse Director and Nurse Manager of the telemetry (cardiac monitoring floor). The medical records are maintained in written and electronic form and require facility staff assistance for review. The medical record was reviewed for nursing pain management evaluation, intervention and response, and for generalized nursing management of systems including skin.

The following was revealed: Medical Record review for pain assessment/evaluation and intervention.
Patient #3: Pain Evaluation 10/18/2010 7:00 p.m. - 10/19/2010 7:00 a.m.
Occurred: 10/19/2010 Time 0000 (Midnight) By: (Insert initials and name of staff nurse.)Recorded: 10/19/2010 Time 0053 (12:53 a.m.) By: (Insert initials and name of staff nurse.) Pain Evaluation Type: Re-evaluationPain score: 0Pain Scale Used: Numbers 0-10Patient Goal for Pain: 0Location: (This is blank-no staff entry.)Onset: (This is blank-no staff entry.)Intensity: (This is blank-no staff entry.)
Character: (This is blank-no staff entry.)Radiation: (This is blank-no staff entry.)Associated symptoms: (This is blank-no staff entry.)Exacerbating Factors: (This is blank-no staff entry.)
Treatment: (This is blank-no staff entry.)
Comment: (This is blank-no staff entry.)Occurred: 10/19/2010 Time 0200 (2:00 a.m.) By: (Insert initials and name of staff nurse.)Recorded: 10/19/2010 Time 0532 (5:32 a.m.) By: (Insert initials and name of staff nurse.)
Pain Evaluation Type: Evaluation (pain management review)Pain score: 5 Pain Scale Used: Numbers 0-1- (on a zero (0)- 10 scale)Patient Goal for Pain: 0Location: All OverLevel of Sedation: Coop/Oriented/Tranquil (Cooperative/Oriented/Tranquil)
Onset: About an hour ago.Intensity: Mildly ModerateCharacter: Pinpricks down LEG/SCROT (Leg and Scrotum).Radiation: Pinpricks down L (left) LEG/SCROTAL area.Associated symptoms: (This is blank-no staff entry.)Exacerbating Factors: (This is blank-no staff entry.)
Treatment: (This is blank-no staff entry.)
Comment: (This is blank-no staff entry.)Occurred: 10/19/2010 Time 0400 (4:00 a.m.) By: (Insert initials and name of staff nurse.)Recorded: 10/19/2010 Time 0053 (5:32 a.m.) By: (Insert initials and name of staff nurse.) Pain Evaluation Type: Re-evaluationPain score: (This is blank- no staff entry.)Pain Schlaer Used: (This is blank-no staff entry.)Location: (This is blank-no staff entry.)Patient Goal for Pain: (This is blank-no staff entry.)Level of sedation: COOP/Oriented/TranquilOnset: (This is blank-no staff entry.)Intensity: (This is blank-no staff entry.)Character: (This is blank-no staff entry.)Radiation: (This is blank-no staff entry.)Associated symptoms: (This is blank-no staff entry.)Exacerbating Factors: (This is blank-no staff entry.)
Treatment: (This is blank-no staff entry.)
Comment: (This is blank-no staff entry.)
Nursing Entries on the Medication Administration Record (MAR): 10/18/2010 7:00 p.m.-10/19/2010 700:a.m. Contains but not limited to:Oxycodone HCL/Acetaminophen (Percocet 5/325 tablet)The following doses were documented as administered:10/18/2010: Time: 1703 (5:03 p.m.) 2 unit dose tablets.10/18/2010: Time: 2104: (9:04 p.m.) 2 unit dose tablets.10/19/2010: Time: 0509 (5:09 a.m.) 2 unit dose tablets.
Morphine Sulfate (Morphine 2MG/ML syringe= Morphine 2 milligrams per milliliter in syringe).
10/19/2010: Time: 0631 (6:31 a.m.) 1 mg Intraven (Intravenous) Administered: "NOW."An interview with the Nursing Director was conducted after the pain evaluation and intervention was reviewed. The Nursing Director explained the expectation of the facility staff nurse is to evaluate for pain as described, per unit policy. The nurse is to document the pain evaluation and the re-evaluation of pain assessment results on the pain management screen in the electronic medical record (EMR). This is to include the information of the type of pain, where it is located and the interventions provided to the patient. The MAR and the pain evaluations and re-evaluations were reviewed.
The director was asked to explain the re-evaluation dated 10/19/2010 at midnight. The nursing director stated "This is a re-evaluation of pain identification. This would indicate a previous pain evaluation."
The Director and the Manager of the floor could not explain the administration of pain medications as documented on the MAR administered at 1703, 2104, 0509, and 0631 (5:03 p.m., 9:04 p.m., 5:09 a.m. and 6:31 a.m.). The Nurse Director stated, "The expectation is the nurse will document the pain finding, the pain intervention and the re-evaluation of pain medication or intervention." When asked to verify the lack of evaluation, re-evaluation and the alignment of the medication administration, the Nurse Director stated, "I cannot explain why this occurred." The Nurse Director was asked about the re-evaluation of pain at midnight and she stated, "I cannot say for sure and cannot speak for the nurse in the ICU (Intensive care unit), but this re-evaluation may be from the medication given at around 9:00 p.m."
The Nurse Director could not explain the medications administered without assessment or follow-up assessment stating, "I cannot answer that, maybe it would be best to speak with the Director of the ICU."The Nurse Director was interviewed regarding the assessment and evaluation of the condition of the skin. She stated, "This would be found in the nursing notes and the shift evaluation. The nursing notes reveal the last entry on 10/18/2010 occurring at 1552 (3:52 p.m.) and recorded on 1557 (3:57 p.m.). The next nursing note entry was dated 10/19/2010 occurring at 0730 (7:30 a.m.) and recorded at 0930 (9:30 a.m.). This note states as follows: "Upon first round PT (patient) was C/O (complaining of) LT (left) hip and scrotal pain. While doing a safety check found PT to have lot of ants on patient and linens. PT was assisted OOB (Out of Bed) to chair. AM (Morning) care completed. Charge Nurse notified. Will transfer patient to a different room (insert room #). Plant OP (Operations) notified. Dr. Khan made aware PT had developed a raised rash on hip, scrotum, and LT leg. After bath PT stated he's feeling much better. Skin barrier CRM (Cream) applied to LT groin/leg and scrotum to ease skin rash. Will continue to monitor."
The 7 a.m. - 7 p.m. ICU nurse shift evaluation dated 10/19/2010 at 0730 (7:30 a.m.) documents a skin assessment including (not limited to) incision, bruises, pressure ulcer (Gluteal fold) and redness in the scrotum/Lt leg and Hip, tissue evaluation: Red and painful, color is red, without drainage. The assessment by the 7 a.m. - 7 p.m. nurse receiving the patient after the room change documents a skin assessment including (not limited to) incision bruises, and pressure ulcer (gluteal fold) and vesicles Left Thigh /Hip, scattered red, one white vesicle left inner thigh. The Nurse Director of the telemetry floor could not explain the 7 p.m. - 7 a.m. absence of skin assessment documentation related to complaints of pain in the left leg and scrotal area at 2:00 p.m. The Nursing Director also could not speak to the lack of pain intervention after the patient complaint of (c/o) pain at 2:00 a.m. The Nurse Director stated, "This (referring to the copies of the MAR, nursing notes and pain evaluations) is the documentation we have in the medical record." A telephone interview was conducted with the 7 a.m. - 7 p.m. nurse receiving Patient #3 on the morning of 10/19/2010. The interview was conducted at 4:55 p.m. through 5:10 p.m. The receiving staff nurse stated the 7 p.m. - 7 a.m. (night shift) nurse was busy with the oncoming day shift nurse (giving report on another patient). The receiving day shift nurse went to the Patient's #3 bedside to initiate the safety check assessment. The nurse remarked the patient stated he "c/o pain all night." The nurse commented the patient's pain was located in the groin, left leg and scrotum. The nurse continued by stating the skin check of the area revealed the patient had "ants all over his legs, groin area, on his penis and scrotal area." The nurse commented the patient stated he was administered pain medications during the night shift. On 10/27/10 at 7:30 a.m. an interview was conducted with the nurse who was assigned to Patient #3 on 10/19/10 from 000 to 0700. She stated Patient #3 was alert and oriented on 10/19/10. She stated the patient complained of "pin pricks" as pain on his leg and scrotum area. In her experience with patients who had a pace maker put in (AICD); this would give the patient an electrical shock feeling. The patient asked her to put the light on and put him on the bed pan. She did not put the light on but turned the patient but went to his right side and turned him to his left to place the bed pan underneath him. At that time she saw graham cracker crumbs in his bed and wiped them up. She did not see any ants. She said this was approximately "3:30ish." He told her he did not need any pain medication. At 5:00 a.m. she gave Patient #3 Percocet because he was complaining of "pin pricks." At 6:00 a.m. she went back to Patient #3 to assess his pain and he told her his pain did not get any better. At that time Morphine was given. She did not re-assess his pain after the Morphine was given. At shift change she did a "pass me safely" session with the nurse who was assigned Patient #3 for the day shift (7:00 a.m. to 7:00 p.m.) on 10/19/10. This was approximately 7:30 a.m. At that time the day shift nurse noticed the ants on Patient #3. The two nurses assisted Patient #3 out of the bed, cleaned him up and moved him to another room. She did not notice any ants throughout the night in his room. When asked if she turned the light on at any time during Patient #3's care she said she did not turn the light on. She would be able to see ants in his room with the lights off.

On 10/27/2010, an interview with the Director of the Intensive Care Unit was conducted at 1:00 p.m. The Director was informed of the pain evaluation, pain interventions, the MAR documentation and the skin assessments. The Director commented the medical record may have additional documentation in the ADL (Activity of Daily Living) screen. The Director returned with additional documentation which included an ADL assist document. This was dated 10/19/2010 as occurring at midnight and recorded at 12:52 a.m. This document indicates there was an assist for repositioning and for a set up for a snack.
An ADL Assistance document dated 10/19/2010 occurring at 2:00 a.m. and recorded at 5:30 a.m. indicated the patient was turned to the left side with assistance and was placed on the bed pan with assistance. Another ADL Assistance document occurring at 2:00 a.m. and recorded at 5:30 a.m. indicated the patient was repositioned to right side, then to back with assistance and assisted with the bedpan. This document also indicates there was no change of linen, bed clothes, oral care, or personal hygiene provided. When asked about the assessment findings including the ADL Assistance the Nurse Director stated the evaluation of the above findings during the survey did offer concerns regarding the care and assessments provided for this patient.
2. The facility records for Patient # 14 were reviewed on 10/27/2010 at 9:40 a.m. with the Nurse Director and the Clinical Supervisor revealed this patient was in the Intensive Care Unit (ICU) post admission for near fainting episodes and possible Coronary Artery Disease. The medical records reveal the patient is intubated (tube into airway providing a set number of respirations with set percentage of oxygen) and receiving intravenous (IV) pain medication as continual infusion. The following are documented pain evaluations for this patient:Occurred: 10/19/2010 Time 2000 (8:00 p.m.) By: (Insert initials and name of staff nurse.)Recorded: 10/19/2010 Time 0053 (9:08 p.m.) By: (Insert initials and name of staff nurse.) Pain Evaluation Type: EvaluationPain score: 8Pain Scale Used: Numbers 0-10Patient Goal for Pain: 0Location: Back Level of Sedation: Anxious and AgitatedOnset: AcuteIntensity: Mildly Moderate
Character: AchyRadiation: BackAssociated symptoms: INCR HR (Increased Heart rate)Exacerbating Factors: (This is blank-no staff entry.)
Treatment: (This is blank-no staff entry.)
Comment: (This is blank-no staff entry.)The medical record reveals the patient did not receive additional pain medication for this pain evaluation. The medical record did not contain documentation of other non-pharmacological interventions at the time the pain was identified and evaluated. The re-evaluation of pain occurred at 2209 (10:09 p.m.) and recorded at 2210 (10:10 p.m.) revealed a reduction in the pain score to a score of 5 (out of a 0-10 pain scale). The re-evaluation of the pain did not include comments or nursing notes indicating the nursing interventions which accomplished the decrease in pain score level.

On 10/19/2010, the documentation reveals a Respiratory Therapy note entry. This evaluation occurred at 0400 (4:00 a.m.) and was recorded at 0507 (5:07 a.m.). The document states "PT (patient) self extubated (patient pulled out the breathing tube) placed on Hi flow nasal cannula per Dr.___ (physician name) PT tolerating well. Will continue to monitor. A Pain Evaluation was completed by a different nurse reveals the patient's Fentanyl drip off (pain and sedation IV infusion).
At 0518 (5:18 a.m.) the assigned nurse completes a nursing note stating, "Went in to PT's room for hourly check. Pt had extubated self even though restrained. Called for help as PT combative with this nurse and has been throughout the night."
The Nurse Director was asked if the medical record contained additional notes from the assigned nurse. The Nurse Director stated, "This is the documentation we have." A review of the ICU flow sheet documentation was conducted. The flow sheet did not contain assessment of the patient's respiratory rate, breathing effort, lung sounds, or respiratory status. The 0400 (4:00 a.m.) entry on the flow sheet includes the heart rate at 96, and a respiratory rate of 27. The Nurse Director stated the Respiratory Therapist notes indicate the patient is tolerating the hi flow oxygen via nasal cannula as "well" and a 4:20 a.m. blood gas reveals an oxygen saturation at 93.9.

The 7 p.m. - 7 a.m. nurse did not provide an updated shift evaluation outlining the continued agitated behaviors, the extubation of the breathing tube, nor to the response to the treatment of the oxygen by nasal cannula. The Respiratory Therapist Ventilator Flowsheet entry at 4:10 a.m. states: PT self extubated Dr ___ (physician name) in room shortly after placed on (Hi Flow Nasal Cannula).
The facility "Shift Evaluation" completed at 0800 (8:00 a.m.) by the 7 a.m. - 7 p.m. nurse reveals the patient is intubated with lung sounds diminished in all fields with a oxygen saturation at 95%. At this time the previous documentation reveals the patient had self extubated and the patient was receiving oxygen via a cannula (two small tubes inserted approximately 1/4 inch into each nostril).

During an interview with the ICU Director on 10/27/10 at 1:15 p.m., she had stated she had reviewed all the clinical records involving the 7 p.m - 7 a.m. nurse in preperation for her meeting with her on 10/28/10. She also indicated the nurse was new to the system, having been hired on 8/9/10 and was still in orientation, being supervised. Regarding the assessment and interventions by this nurse conducted on the 7 p.m. - 7 a.m. shift, she could not comment to the survey findings regarding Patient #14 by commenting the Risk Management was conducting an investigation and Patient #14's medical record had not yet been reviewed.

The ICU Director and the Risk Manager confirmed that on the 7 p.m - 7 a.m shift on 10/18-10/19/10, this nurse was only assigned these two patients (#3 and #14). The ICU director confirmed she failed to review the chart of the other patient (Patient # 14) assigned to this nurse that night.

3. A review of Patient #19's medical record on 10/27/10 showed on 10/22/10 at 1700 the patient complained of pain at a number 3 on a scale of 1 to 10. The patient also complained at 11:26 a.m. of pain at a number 8 on a scale of 1 to 10. This review was on the pain monitoring form. Further review of this medical record showed there were no interventions made by the nurse when Patient #19 complained of these pains. The nurse's notes, Medication Administration Records, evaluations, re-evaluations and pain management monitoring forms were reviewed, along with several other areas of the patient record reviewed and showed the patient did not receive any interventions concerning these two complaints of pain.

Interview with the nurse on 10/27/10 at 1:45 p.m. stated she was not able to find any documentation the patient received any intervention for these two complainants of pain.

4. A review of Patient #4's medical record on 10/27/10 showed on 10/24/10 at 0800 the patient complained of pain at a 7 on a scale of 1 to 10. A review of the Medication Administration Record (MAR) showed the patient received Fentanyl. On 10/23/10 at 0800 the patient complained of pain and the nurse gave medication and changed the patient's position. However, with these two interventions to relieve Patient #4's pain there was no documentation in her record to show the nurses re-assessed the patient to ensure these interventions relieved her pain.

Interview with the nurse on 10/27/10 at 9:45 a.m. stated she was not able to find anywhere in the patient record where re-assessments occurred. This nurse then asked another nurse from this unit where to find these re-assessments. The nurse told her re-assessments will be found either in the nurse's notes, evaluations, re-evaluations, or the pain monitoring form. These forms were reviewed and there was no documentation of a re-assessment.

5. A review of Patient #5's medical record on 10/27/10 showed on 10/19/10 at 0800 the patient complained of pain at a 7 on a scale of 1 to 10. The patient was given Percocet. On 10/23/10 at 0309 the patient complained of pain at a 3 and the patient was given Morphine. On 10/23/10 at 0907 (9:07 a.m.) the patient complained of pain at a 6 and was given Percocet. Further review of Patient #5's medical record showed there were no re-assessments of the patient for the interventions used to relieve the pain.

An interview was conducted with a nurse on the unit at 10:45 a.m. She stated if a patient complains of pain and is given an intervention for this pain an assessment within the first hour should be done. This assessment should be documented on the pain evaluation form or the re-evaluation sheet. Another review of these two forms was completed and there was no documentation of the re-assessments.

6. A review of Patient #6's medical record on 10/27/10 showed on 10/20/10 at 2010 the patient complained of pain. A review of the MAR showed pain medication was given. Further review of this record showed there was no documentation of a re-assessment on Patient #6 to evaluate if the medication intervention was successful.

7. A review of Patient #7's medical record on 10/27/10 showed on 10/27/10 at 0000 (12:00 a.m.) the patient complained of pain at an 8 on a scale on 1 to 10. He was given medication and repositioned. The patient complained of pain at 0445 at an 8. He was given medication. Further review of this medical record showed there was no documentation of re-assessments completed once the patient was given medications for his pain either time.

Interview with the nurse at 11:00 a.m., who was reviewing the chart, stated she was not able to find the documentation of the re-assessments for these two interventions for pain. She re-iterated she looked in the areas of the patient's medical record where the nurse on this unit would document a pain re-assessments.

8. A review of Patient #18's medical record on 10/27/10 showed on 10/26/10 at 0800 the patient complained of pain at an 8 on a scale of 1 to 10. The patient was given Dilaudid. At 1009 (10:09 a.m.) the patient complained of pain and was given Dilaudid again. Documentation showed the nurse re-assessed the patient's pain at 1200. However, there was no re-assessment of the first intervention of Dilaudid given at 0800.

An interview was conducted with the Unit Nurse at 1:15 p.m. on 10/27/10. She went through Patient #18's medical record and stated she, also, could not find any documentation of a re-assessment done when the patient was given medication for his pain at 0800.

Based on a review of 1 (Patient # 3) of 20 patient records and staff interview, the facility failed to ensure Patient #3's medical record was maintained accurately.

The findings include:

A review of Patient #3's medical record on 10/26/10 showed on 10/19/10 at 0200 (2:00 a.m.) the patient was assisted on the bedpan and complained of "pin pricks." This was documented at 0532 (5:32 a.m.). At 0400 (4:00 a.m.) the nurse re-evaluated Patient #3's pain and assisted the patient with a urinal. The pain evaluation was documented at 0532 and the assistance with the urinal was documented at 0530 (5:30 a.m.).

On 10/27/10 at 7:30 a.m., an interview was conducted with the registered nurse, who documented these events and who was assigned to Patient #3 on 10/19/10 from 000 to 0700 (7:00 a.m.). She stated she documented these two entries but they were not accurate. She stated there was no patient contact at 0200 (2:00 a.m.) and 0400 (4:00 a.m.) for Patient #3. She was asked again about these two entries and she stated the documentation was an error on her part and there was no patient contact.