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Based on interviews and document review the facility failed to have a consistent procedure to ensure patients were assessed for pain on a regular basis and reassessed for pain following an intervention for 10 of 25 inpatient records reviewed (Patients #2, #3, #5, #6, #9, #12, #22, #23, #28 and #30).

This failure created the potential for inadequate pain relief and management.

Findings include:

Policy

The Documentation of Nursing Care Policy read a plan of care is formulated upon completion of the admission assessment and reprioritized every shift and as the patient condition requires. A care plan should be added to documentation on admission. Pain should be assessed every four hours and as needed.

The Assessment and Reassessment of Patients Policy read the purpose was to provide a guideline to assist the healthcare team to provide appropriate, safe and effective care to the patient. The plan of care is completed on admission and revised upon reassessments of the patient and effectiveness of interventions. The Registered Nurse (RN) will evaluate the effectiveness of interventions.

The Treatment of Pain Policy read reassessment of pain is critical to success in addressing pain and subsequent reevaluation of the care plan. The nurse acts as the patient's advocate and agent to communicate an inadequate plan to the physician and discuss changes. This is an ongoing cycle that utilizes the nursing process to assess, plan, implement, reassess and if necessary, revise the plan.

The use of pain as the 5th vital sign is the standard of practice. Obtaining a pain rating is indicated after intervention to evaluate effectiveness of the care provided as well as on a routine basis such as the schedule used to obtain other vital signs.

References

The Academy of Medical Surgical Nurses position statement published on 11/7/2012 provided by Director #4 read, pain management should be the priority of care for every patient. Pain should be reassessed after an intervention or change in the treatment regimen. Pain medication should be administered around the clock to optimize pain management.

1. The facility failed to ensure pain assessments and reassessments were performed as required to ensure patients were not in pain.

a. On 4/18/18 Patient #5 was admitted for post-operative rehabilitation of her heel and wrist fractures. The patient was ordered Tylenol 650 mg to 975 mg every six hours as needed and Oxycodone Immediate Release (IR) (a narcotic to treat moderate to severe pain) 5-10 mg every four hours as needed for pain.

Patient #5 received pain medication on eight occasions in which reassessments were not completed. For example: According to the Medication Discharge Summary, Patient #5 received Tylenol 975 mg on 4/20/18 at 12:42 a.m., there was no pain reassessment until 8:00 a.m. Additionally, Patient #5 received Tylenol 975 mg at 8:53 a.m., and pain was not reassessed until 12:00 p.m.

Pain Assessments provided by Manager #5 revealed Patient #5 had intermittent pain assessments from 4/20/18 at 5:15 p.m. to 4/25/18 at 9:46 a.m. During this time period the patient was not consistently assessed for pain every four hours as specified in the policy.

b. Patient #2 was admitted on 1/28/18 at 2:55 p.m. for colitis (inflammation of the colon). Patient #2 was discharged on 1/31/18. She had orders for Tylenol 650 mg every six hours as needed and Oxycodone IR 5 mg every 4 hours as needed for pain. According to the pain documentation, Patient #2 was not consistently assessed for pain every four hours as specified in the policy during her length of stay. Patient #2 received pain medication five times, but only had her pain reassessed two times during her hospitalization.

On 4/25/18 at 2:02 p.m., Director #4 reviewed Patient #2's medical record and stated there were missing pain assessments and reassessments. Director #4 verified Patient #2 only had two pain assessments completed during her entire hospitalization. Director #4 further verified Patient #2 had no pain reassessments completed after she received narcotics for pain.

c. Patient #9 was hospitalized from 3/26/18 to 3/28/18 for a surgical hernia repair (occurs when an organ pushed through an opening). Patient #9 was ordered Norco (a narcotic pain medication) 5/325 mg every four hours as needed, Morphine (a narcotic pain medication) 1 mg every hour as needed and Ofirmev (non-narcotic pain medication) 1000 mg by IV every six hours as needed for pain relief. Patient #9 was medicated 18 times during her hospitalization and reassessed for pain relief during the expected time frame only one time.

d. On 4/26/18 at 9:52 a.m., an interview with RN #6 was conducted. RN #6 stated pain should be assessed routinely every two to four hours. RN #6 further stated pain should be reassessed 30 minutes to one hour after a medication was given by mouth and within 15 to 30 minutes after administering pain medication intravenously (IV). RN #6 stated the reason to perform a reassessment after giving a pain medication was to evaluate the effectiveness of the pain medication. RN #6 stated the Medication Administration Record (MAR) would normally trigger staff to reassess the patient for pain relief after a medication was given, but recently that had not been occurring. RN #6 also stated she was educated on when to assess patients for pain during her initial orientation to the facility.

e. On 4/26/18 at 10:03 a.m., an interview with Director #4 was conducted. Director #4 stated nurses were prompted to assess pain every four hours in the electronic health record (EHR). Director #4 stated the expectation for pain reassessment was within 30 minutes to one hour after a medication was given by mouth and within 15 to 30 minutes after a pain medication was given by IV. Director #4 stated she became aware the EHR had not been prompting staff to reassess pain during the survey. Director #4 stated staff was trained when to assess and reassess pain during their initial orientation and annually. Director #4 also stated she had not been auditing staff compliance with assessing pain.

f. On 4/26/18 at 10:03 a.m., a joint interview with Chief Nursing Officer #7 was conducted. CNO #7 stated the expectation was for a routine pain assessment to be performed every two to four hours. CNO #7 further stated the expectation for pain reassessment was within 30 minutes to one hour after a pain medication was given by mouth and within 15 to 30 minutes after a pain medication was given intravenously. CNO #7 stated the reason for a pain reassessment was to ensure the patient had received the proper effectiveness of the pain medication. CNO #7 stated the reason staff were not receiving notifications prompting a pain reassessment was due to an update to the EHR three months prior.

Based on observations, interviews, and document review the facility failed to ensure manufacturer instructions were followed in regard to storage of medication. The failures were identified in 2 of 4 observations conducted throughout the facility.

Findings include:

Reference:

According to the Hospira instructions for intravenous solutions in plastic flexible containers, in their overwraps, may be warmed at the maximum temperature of 104 degrees fahrenheit for no longer than 2 weeks (14 days). Furthermore, once the product is removed from the warming cabinet, it should be clearly labeled with a revised expiration date. If the warmed product is not used immediately, it can be returned to 77 degree fahrenheit storage and used until the revised expiration date. Solutions should not be re-warmed.

1. The facility failed to ensure intravenous (IV) solutions in plastic flexible containers were labeled with a revised discard date when placed into the warming cabinet.

a. On 4/23/18 at 4:37 p.m. observations were conducted of the diagnostic imaging (imaging) department. The observation at that time revealed a warming cabinet stocked with seven 100 mL 0.9% sodium chloride IV solutions (normal saline). The normal saline solutions stocked in the warming cabinet were not labeled with the appropriate 14-day discard date.

b. Similar findings were identified in the imaging department again on 4/25/18 at 9:00 a.m. Observation at that time revealed the warming cabinet was stocked with nine bags of 100 mL normal saline. The solutions were not labeled with a discard date while in the warming cabinet.

c. On 4/25/18 at 9:05 an interview was conducted with a radiology technician (RT #8). RT #8 stated the IV solutions in the warming cabinet were good until the manufacture expiration date of November 2018.

d. On 4/25/18 at 1:10 p.m., an interview was conducted with the diagnostic imaging department director (Director #9). Director #9 stated the imaging staff were not expected to label IV normal saline stored in warming cabinets with a 2 week discard date.

On 4/25/18 at 2:25 p.m., Director #9 reviewed the manufacturer instructions for the normal saline solutions in flexible plastic containers and confirmed the bags should have been labeled with a 2 week discard date once placed in a warming cabinet.

Based on observations and interviews the facility failed to ensure point of care testing materials were dated when opened.

1. The facility failed to ensure the test strips required for glucometer testing and quality control were labeled with the appropriate discard date.

Findings include:

Reference:

According to the user guide of the Ascensia Contour Blood Glucose Monitoring System, always use test strips within 6 months (180 days) after opening the bottle. Don't forget to write the "discard date" in the space provided on the bottle label. Always check the expiration date on the test strip bottle or box. If the test strips have expired, replace with new test strips.

a. On 4/25/18 at 10:00 a.m., an observation was conducted of the perioperative (surgical) department. The observation revealed the test strips used with the glucometer (device used for testing blood glucose levels) were opened without the required discard date labeled on the bottle.

b. On 4/25/18 at 10:30 an interview was conducted with a perioperative registered nurse (RN #10). RN #10 stated the test strips did not require a discard date labeled when opened because the test strips were good until the manufacturer's expiration date. RN #10 was unaware of the requirement for a discard date once the bottle was opened.

c. On 4/25/18 at 12:52 p.m., an interview was conducted with the director of surgery (Director #11). Director #11 confirmed the perioperative staff were not trained to label the glucometer test strips once opened with the applicable discard date according to the manufacturer instructions. Director #11 reviewed the manufacturer instructions and confirmed the teststrips bottles should have been labeled with the 6 month discard date. Director #11 stated it was important to not use test strips after the discard date in order to ensure the accuracy of the glucometer results.

Based on document review and interviews the facility failed to ensure all admitted patients received an individualized nursing care plan. The failure was identified in 10 of 25 inpatient medical records reviewed (Patient's #6, #7, #9, #12, #17, #22, #23, #27, #28, and #29).

Findings include:

Policy:

The policy, Nursing Care Plan, stated upon admission of a patient the nurse will assign a nursing care plan to the patient within the EHR. As "per the Joint Commission, an individualized plan of care will be developed and documented for each patient." The nurse will review the care plan and revise it as needed to reflect the needs of the patient. The care plan will describe the patient goals and appropriate physiological and psychological factors and discharge planning for the patient.

The Documentation of Nursing Care Policy read a plan of care is formulated upon completion of the admission assessment and reprioritized every shift and as the patient condition requires. A care plan should be added to documentation on admission.

1. The facility failed to ensure all patients received an individualized nursing care plan upon admission to the hospital.

a. A record review of Patient #6's medical record was conducted. Review of the medical record revealed it was missing an individualized nursing care plan.

On 4/24/18 at 4:12 p.m., an interview was conducted with the director of the medical/surgical department (Director #4). During the interview, Director #4 reviewed the medical record for Patient #6 and confirmed an individualized nursing care plan was not documented in the medical record.

b. A record review of Patient #7's medical record was conducted. Similarly, the review revealed it was missing an individualized nursing care plan.

On 4/24/18 at 4:12 p.m., Director #4 reviewed the medical record for Patient #7 and confirmed an individualized nursing care plan was not documented in the medical record.

c. A medical record review for Patient #17 was conducted. Review of the medical record also found it was missing an individualized nursing care plan.

On 4/24/18 at 4:12 p.m. Director #4 reviewed the medical record for Patient #17 and confirmed an individualized nursing care plan was not documented in the medical record.

d. Similar findings regarding missing nursing care plans was identified in the medical records of Patient's #9, #12, #22, #23, #27, #28, and #29.

e. On 4/25/18 at 1:37 p.m., an interview was conducted with a registered nurse (RN #2) staffed on the medical/surgical unit. RN #2 stated an individualized nursing care plan must be documented for all admitted patients. According to RN #2, the nursing care plan must be specific to the patient's needs, diagnosis, health history, and educational needs.

f. On 4/25/18 2:02 p.m., another interview was conducted with Director #4. Director #4 stated the nursing care plans were important in guiding nursing care for all admitted patients. It was also stated that nursing care plans helped identify the specific educational teaching and treatment goals applicable to each patient. Lastly, it was stated the nursing care plans addressed how the patient was progressing with the treatment plan.

Director #4 stated that she was aware nursing care plans were a weakness in the medical records. However, Director #4 stated no process was in place to monitor patient medical records for documentation of an individualized nursing care plan.

Based on interviews and document review the facility failed to assure all staff and volunteers were trained in their respective roles during a disaster.

Findings include:

Policy

According to Resolution for the Formal Adoption of the National Incident Management System, response and recovery from major disasters requires integrated professional management and coordination along with training of personnel responsible for managing and/or supporting major emergency disaster operations.

1. The facility failed to train all personnel on their responsibilities during emergency disaster operations.

a) During an interview with the Director of Medical/Surgical care (Director #4) on 4/25/18 at 2:02 p.m., she stated the facility did not involve direct patient care staff in disaster preparedness training. Some of the directors had completed the FEMA (Federal Emergency Management Agency) courses for disaster preparedness. According to Director #4 the facility conducts regular fire drills and there had been one table top exercise completed in the last year. She added, the facility planned to include emergency preparedness in the upcoming skills competency fair for staff.

b) On 4/25/18 at 8:23 a.m., an interview was conducted with the Chairman of the Emergency Preparedness Committee (EP #1). EP #1 stated the department directors of the facility had completed the FEMA training courses on disaster preparedness but no specific training had been provided to the frontline staff of the facility. According to EP #1, "we are small enough that we will always have accessibility to leadership staff."

c) An interview was conducted with Registered Nurse (RN) #2 on 4/25/18 at 1:37 p.m. According to RN #2, who is also a charge nurse in the patient care unit, she had received training on fire drills but no training on the disaster plan for the facility.

Based on interviews and record reviews the facility failed to conduct, document and evaluate an annual full-scale emergency preparedness exercise. This failure created the potential for an ineffective response which would negatively impact the safety and well-being of patients and staff.

Findings include:

Policy

According to Resolution for the Formal Adoption of the National Incident Management System, response and recovery from major disasters requires integrated professional management and coordination along with training of personnel responsible for managing and/or supporting major emergency disaster operations.

1. The facility failed to conduct a full-scale exercise to test the effectiveness of its emergency preparedness plans.

a) An interview was conducted with the Chairman of the Emergency Preparedness Committee (EP #1) on 4/25/18 at 8:30 a.m. He explained, the facility had conducted a table top exercise in September 2017 but he was not in attendance. EP #1 stated, the facility had focused on updating the Event Operations Plan (Green Book) to ensure all contact information for leadership was available in every department. EP #1 was not able to provide any documentation to show the facility had conducted a full-scale test of its emergency preparedness plan.

b) On 4/25/18 at 1:37 p.m., an interview was conducted with Registered Nurse (RN) #2, who was a charge nurse for the inpatient care unit. RN #2 stated she had participated in regular fire drills and active shooter training but had never been involved in any evacuation drill or received disaster training.

c) The Manager of Facilities Safety and Security (Manager #3) was interviewed on 4/26/18 at 8:15 a.m. Manager #3 confirmed he was a member of the Emergency Preparedness Committee. According to Manager #3, no full-scale exercise had been conducted by the facility, only a table top exercise. Manager #3 confirmed all documentation related to the emergency preparedness plan had been provided to the surveyor.