HospitalInspections.org

Based on review of facility documents and medical records (MR), and staff interviews (EMP), it was determined the facility failed to follow their policy related to tracking Patient Controlled Analgesia (PCA) pump medication usage and failed to ensure pain assessments were completed in a timely manner for two of 20 patients (MR1 and MR3).

Review of the "Patient Assessment/Reassessment" policy revised July 2014 revealed, "PAIN ASSESSMENT All patients will be screened for the presence of pain upon admission, at regular intervals and, prior to and following an invasive procedure. If present, pain shall be assessed. ...REASSESSMENT...Frequency of reassessment will be determined by individual patient care needs..."

Review of the "Medication Administration" policy revised August 2014 revealed, "ACTION/TIME FRAME...16. Document pre and post intervention pain scores on the appropriate section of the EHR or MAR or flowsheet when administering analgesics."

Review of the "Patient Controlled Analgesia (PCA), Care of the Patient" policy revised August 2014 revealed, "Clear history every 8 hours and document total dose delivered in E-Record."

1. Review of MR1 on September 18, 2015, at approximately 9:40 AM revealed the patient was admitted to the facility with diagnosis of chronic pain syndrome. The patient was ordered a PCA pump on August 6, 2015, which was initiated at 1:46 PM. Between 2:00 PM and 8:00 PM this date (period of six hours after initiation of PCA), there were no documented pain assessments. On August 7, 2015, at 4:00 AM the patient's pain was reported as 9/10. There were no further documented pain assessments until approximately 1:00 PM (nine hours later).

2. Continued review of MR1 revealed documentation on August 6 at 10:11 PM, that the total dose of pain relieving medication delivered to the patient per PCA pump (from 1:46 PM) was 4 mg. On August 7 the PCA history was also cleared at 04:56 AM and the total dose delivered (from 10:11 PM) was only 2 mg. There was no documentation of how much pain medication was administered to the patient via PCA between 04:56 AM and the time the PCA was discontinued.

During an interview on September 18, 2015, at approximately 1:50 PM, EMP6 confirmed the above findings related to pain assessments and PCA dose delivered documentation.

During another interview on September 18, 2015, at approximately 2:40 PM, EMP16 also confirmed the above findings.

3. Review of MR3 on September 18, 2015, at approximately 11:30 AM revealed that the patient was administered a pain medication on September 16, 2015, at 12:38 PM, for a pain score of 8, on a scale of 1-10; at 5:25 PM for a pain score of 7, and again at 9:23 PM for a pain score of 8. There was no evidence that the patient's pain was reassessed after each pain medication administration.

During an interview on September 18, 2015, at approximately 3:00 PM, EMP6 confirmed that there was no evidence that MR3's pain was reassessed after pain medication was administered on September 16, 2015.