HospitalInspections.org

Based on medical record review, P & P and staff interview staff failed to ensure that patients suffering from pain and cardiac complications have a plan of care that is current, updated, and adjusted as indicated by patient assessment and reassessment, and interventions are individualized to specific patient needs in 10 of 10 MR's reviewed (Pt #1,2,3,4,5,6,7,8,9,10) and 2 of 2 staff interview (RN B, CNO C). This could potentially effect all patients at this facility experiencing pain and cardiac complications.

Findings include:

Review on 1/21/14 beginning at 11:00 am of P & P titled, "Assessment/Reassessment of Patients" effective 11/08 states the following,
-The reassessment is designed to evaluate the patient's response to care and interventions and to determine if a change in the plan of care is warranted.
-Nursing reassessment is done when the patient's condition warrants and/or when there is a significant change in patient's condition.
-The RN will modify the plan of care based on patient response and evaluation of effectiveness of interventions.

Review on 1/21/14 beginning at 11:00 am of P & P titled, "Pain Management of the Adult Patient" effective 7/13 states the following,
-If initial interventions are not effective in decreasing pain to an acceptable level, additional methods of pain relief will be sought.
-If relief is inadequate, the physician will be notified to discuss the need for alternative pharmacological interventions.
-Each patient will be reassessed for the presence/absence of pain following paint management interventions.
-The frequency of assessment will be increased based on patient status including moderate/severe pain ratings.
-Timing of reassessment should be determined by the expected onset of the pain relief intervention. Oral analgesic--1 hour after; injectable analgesic--30 minutes after, PCA (Patient controlled anesthesia) per policy.

Review on 1/21/14 beginning at 11:00 am of P & P titled, "Patient Controlled Analgesia(PCA)" effective 1/2014 states the following,
-The nurse must assess the patient for side effects; in particular, sedation and respiratory depression. Level of sedation and respiratory rate and depth are key assessment parameters during opioid therapy.
-The frequency of ongoing assessment of level of sedation, vital signs, O2, pain level and quality of respirations at initiation of opioids, change of drug/syringe, change of shift, or with adverse event should be---Every 15 minutes x 4; Every 1 hour x 4; Every 2 hours thereafter or as required by patient conditions or risk factors.

Per interview with CNO C on 1/22/14 beginning at 3:00 PM, PCA P & P was effective as of 1/2014 however staff have not yet been informed and educated on this new policy.

Review on 1/21/14 beginning at 11:00 am of "Post Operative Management" practice guidelines last revised 12/04 state,
-Monitor post surgical VS every hour x 2, then if stable, every 4 hours x 24 hours, then if stable, every 8-12 hours.
-Monitor for pain every 2 hours

Findings:

Review of Pt #1's MR on 1/21/14 beginning at 1:25 PM revealed Pt #1 was admitted to the hospital on 10/5/13 at approximately 11:00 am with a diagnosis of severe acute Crohn's disease with small bowel obstruction. On 10/7/13 at 12:30 PM Pt #1 had a colon resection performed in the operating room under general anesthesia. Per nursing assessment documented at 4:00 PM Pt #1 has a Morphine PCA pump for pain control. Review of the vital signs (VS) flow sheet dated 10/7/13 reveals VS's including respiratory rate and O2 saturation taken at 3:57 PM, 5:05 PM and then not again until 10:04 PM. Per nursing assessment flowsheet dated 10/7/13 through 10/11/13 nursing assessments do not consistently document Pt #1's level of sedation, VS's, O2 saturation, pain level, and quality of respirations while being on a Morphine PCA pump as per the PCA P & P to prevent potential respiratory depression.
Per review of nursing assessment comfort flowsheet dated 10/10/13, Pt #1 complained of the following pain levels while using a Morphine PCA pump:
7:00 PM--8 out of 10
8:00 PM--10 out of 10
8:30 PM--10 out of 10
9:30 PM--10 out of 10
11:30 PM--10 out of 10
No evidence in Pt #1's MR of staff changing and/or adjusting Pt #1's pain management interventions to reduce Pt #1's pain level. Review of Pt #1's nursing assessment dated 10/10/13 reveals Pt #1's site of acute severe pain was located in Pt #1's abdomen, review of Gastrointestinal (GI) nursing assessment documentation corresponding to the above 10 out 10 pain documentation times, revealed staff did not consistently document assessing Pt #1's GI system to monitor for signs and symptoms of physiological complications post GI surgery.

Per review of Pt #1's VS's flowsheet dated 10/10/13, Pt #1 had the following BP's and pulse:
5:27 PM--78/46 pulse 137
6:17 PM--79/49 pulse 126
8:27 PM--78/44 pulse 119
Review of Pt #1's nursing assessment flowsheet dated 10/10/13 at the corresponding times, reveals no Cardiac nursing assessment documentation assessing signs and symptoms of Pt #1's elevated pulse and low blood pressure and interventions completed. Pt #1's BP was not checked for more then 2 hours after obtaining a very low BP of 79/49 and pulse of 126.

Per interview with Manager B on 1/21/14 beginning at 10:25 am, staff should have assessed Pt #1's for signs and symptoms of elevated heart rate and low blood pressure, and documented assessment findings and interventions in the Cardiac nursing assessment flowsheet. Per Manager B, Pt #1's BP and pulse should have been checked at least every 15 minutes with it being that low.

Review of Pt #2's MR on 1/22/14 beginning at 11:15 am shows Pt #2 had Sigmoid Colon Resection surgery on 10/16/13 beginning at 9:00 am. Per review of Pt #2's PACU(post anesthesia care unit) notes Morphine PCA pump was started on 10/16/13 at 1:26 PM and Pt #2 was transferred to the inpatient unit at 3:00 PM. Pt #2's nursing assessment flowsheet dated 10/16/13 shows no evidence of an assessment of Pt #2's level of sedation, pain level, and quality of respirations until 6:13 PM while on a Morphine PCA pump; this was more then 3 hours after admission to the floor; and on 10/17/13 between 8:30 am and 1:42 PM, more then 5 hours between nursing assessments. Pt #2's VS flowsheet dated 10/16/13 shows no evidence of VS's being taken including respiratory rate and oxygen saturation, from 3:06 PM to 6:46 PM, more then 3 hours between VS check; and on 10/17/13 no VS taken between 1:23 am to 6:17 am, more then 4 hours between VS check.

Review of Pt #3's MR on 1/22/14 beginning at 11:55 am shows Pt #3 had colon resection surgery on 10/8/13 beginning at 6:46 am. Pt #2 transferred to inpatient floor at 10:30 am. Per Pt #3's VS flowsheet, Post surgical VS's done at 10:45 am and 11:38 am, and then not done until 6:10 PM, over 6 hours later. At 5:07 PM Pt #3 given Morphine 2 mg IV injection, Pt #3's nursing assessment flowsheet shows no evidence of pain reassessment until 10:14 PM; more then 5 hours later. At 10:14 PM Pt #3 given Morphine 2 mg IV injection, no evidence of pain reassessment until 2:05 am; more then 3 hours later.

Review of Pt #4's MR on 1/22/14 beginning at 12:15 am shows Pt #4 admitted to hospital on 10/11/13 and received colon surgery on 10/13/13 at 2:05 PM. On 10/12/13 and 10/13/13, Pt #4 had the following documented abdominal pain levels out of 10:
10:30 PM--8
10:49 PM--8 given Dilaudid 0.5 mg IV injection
11:09 PM--8
2:06 am--9 given Dilaudid 0.5 mg IV injection
6:20 am--10 given Dilaudid 0.5 mg IV injection
6:50 am--10
7:30 am--10 given Dilaudid 0.5 mg IV injection
8:00 am--9
9:30 am--10 given Dilaudid 0.5mg IV injection

Review of Pt #4's nursing assessment flow sheet shows no evidence of staff changing and/or adjusting Pt #1's pain management interventions to reduce Pt #1's pain level when the current interventions are not working and Pt #1 is not reaching pain goal.

Review of Pt #5's MR on 1/22/14 beginning at 12:45 PM shows Pt #5 had colon surgery on 11/5/13 beginning at 9:30 am. Pt #5 was transferred to the inpatient floor at 12:10 PM. Review of the VS flowsheet dated 11/5/13 and 11/6/13 showed the following low BP's:
11/5/13 at 5:45 PM--BP 89/52
6:01 PM--BP 90/52
6:23 PM--BP 83/50
7:08 PM--BP 87/51
8:47 PM--BP 70/41
11/6/13 at 2:20 am--BP 79/44
Review of Pt #5's nursing assessment flowsheet dated 11/5/13 and 11/6/13 shows no evidence of a Cardiac nursing assessment and interventions completed of Pt #5's low blood pressure until 9:01 PM on 11/5/13, more then 3 hours after initial low BP documentation. Pt #5's BP was 79/44 on 11/6/13 at 2:20 am, no evidence of nursing cardiac assessment until 7:56 am, more then 5 hours later. Cardiac IPOC (interdisciplinary plan of care) does not show evidence of an individualized POC containing measurable goals and specific interventions done to address Pt #5's low BP.

Review of Pt #6's MR on 1/22/14 beginning at 1:00 PM show Pt #6 had colon surgery on 11/12/13 beginning at 9:40 am. Pt #5 was transferred to the inpatient floor at 3:21 PM. Per Pt #6's Medication Administration record, Morphine PCA Pump was initiated on 11/12/13 at 4:37 PM for pain control. Nursing assessment flowsheet dated 11/12/13 show no evidence of a nurse assessment of Pt #6's level of sedation, pain level, and quality of respirations between 4:31 PM and 9:05 PM, more then 4 hours. Pt #6's VS flowsheet dated 11/12/13 shows no evidence of checking VS's between 4:46 PM and 8:52 PM.

Review of Pt #7's MR on 1/22/14 beginning at 1:15 PM show Pt #7 had colon surgery on 12/17/13 beginning at 9:27 am. Pt #7 was transferred to the inpatient floor at 12:11 PM. Per nursing assessment flowsheet Pt #7 using Morphine PCA pump. Nursing assessment flowsheet dated 12/17/13 show no evidence of a nurse assessment of Pt #7's level of sedation, pain level, and quality of respirations between 1:01 PM and 5:00 PM, 4 hours between nursing assessments. Pt #7's VS flowsheet dated 12/17/13 shows no evidence of checking VS's including respiratory rate and oxygen saturation from 1:40 PM to 5:42 PM.

Review of Pt #8's MR on 1/22/14 beginning at 1:30 PM show Pt #8 had colon surgery on 12/23/13 beginning at 8:42 am. Pt #8 transferred to inpatient floor at approximately 12:45 PM. Per Pt #8's medication administration record, Morphine PCA pump initiated at 12:00 PM for pain control. Nursing assessment flowsheet dated 12/23/13 show no evidence of a nurse assessment of Pt #8's level of sedation, pain level, and quality of respirations between 1:04 PM and 4:56 PM, 4 hours between nursing assessments. Pt #8's VS flowsheet dated 12/23/13 shows no evidence of checking VS's including respiratory rate and oxygen saturation from 2:13 PM to 5:30 PM.

Review of Pt #9's MR on 1/22/14 beginning at 1:45 PM show Pt #9 had colon surgery on 12/29/13 beginning at 8:20 am. Pt #9 transferred to inpatient floor at 11:50 am. Per Pt #9's medication administration record, Morphine PCA pump initiated at 11:00 am for pain control.
Nursing assessment flowsheet dated 12/29/13 show no evidence of a nurse assessment of Pt #9's level of sedation, pain level, and quality of respirations between 12:34 PM and 2:53 PM, more then 2 hours between nursing assessments. Pt #9's VS flowsheet dated 12/29/13 shows no evidence of checking VS's including respiratory rate and oxygen saturation from 1:05 PM to 5:44 PM.

Review of Pt #10's MR on 1/22/14 beginning at 2:00 PM show Pt #10 had colon surgery on 12/28/13 beginning at 12:20 PM. Per Pt #10's medication administration record, Morphine PCA pump initiated at 3:00 PM for pain control. Nursing assessment flowsheet dated 12/28/13 show no evidence of a nurse assessment of Pt #10's level of sedation, pain level, and quality of respirations between 3:31 PM and 8:40 PM, more than 5 hours between nursing assessments. Pt #10's VS flowsheet dated 12/28/13 shows no evidence of staff checking VS's including respiratory rate and oxygen saturation from 4:31 PM to 6:30 PM.