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WEST CHESTER HOSPITAL, LLC
STAFFING AND DELIVERY OF CARE
Tag No.: A0392
Based on record review, interview, and policy review, the facility failed to provide pain management in a timely manner. This affected one (Patient #7) of ten patients reviewed.
Findings include:
Review of the medical record revealed Patient #7 was admitted to the hospital on 05/09/23 for a scheduled laminectomy surgery and was discharged to home on 05/12/23.
Review of the medical record revealed Patient #7 was transferred from the Post-Anesthesia Care Unit (PACU) to Medical-Surgical (MedSurg) 4 unit on 05/09/23 at 4:37 P.M. At 4:41 P.M. the patient complained to the nurse she was experiencing pain to her back, rating it a ten on a one to ten pain scale.
Review of physician orders revealed on 05/09/23 at 4:56 P.M., the physician placed an order for Dilaudid 1 milligram (mg) intravenously (IV) every two hours as needed for pain with a pain scale rating between seven and ten.
Review of the pain assessment completed on 05/09/23 at 5:20 P.M. revealed Patient #7 complained of continuous sharp back pain, rating it an eight on a one to ten scale. A cold pack was applied.
Review of the medical record revealed the pharmacy verified the order for Dilaudid 1 mg IV every two hours as needed for severe pain on 05/09/23 at 5:26 P.M.
Review of the Medication Administration Record revealed Patient #7 received the first dose of Dilaudid 1 mg IV on 05/09/23 at 6:00 P.M.
During an interview on 12/06/2032 at 10:13 A.M. RN Clinical Informatics Specialist P verified Patient #7 did not receive post-op pain medication on 05/09/23 until 6:00 P.M. after having complained of pain at 4:41 P.M.
Review of the policy titled "Pain Management", dated 12/30/15, revealed patients had the right to appropriate assessment and management of pain consistent with the total treatment plan. The nurse completed a pain assessment and attempted non-pharmacological pain interventions before administering pain medications and completed a pain re-assessment within 45 minutes for IV administrations and within 90 minutes of oral administration to determine the effectiveness and safety of pain interventions.