HospitalInspections.org

Based on interview, record review and a review of facility documentation, the facility failed to ensure that the care plan for each patient concerning reassessments after the administration of a medication for a complaint of pain was followed according to policy for one of four sampled patients. (#1)

Findings:

A review of the medical record of patient #1 was performed. The patient was admitted to the Emergency Department (ED) on 3/16/23.

The History & Physical of 3/16/23 at 1:49 PM read: "She came to the emergency department today where lab work shows slight hyperglycemia. EKG (electrocardiogram) did not show any acute ST segment changes. Chest x-ray did not show any acute cardiopulmonary process. She has a strong family history for aneurysms in her family and her parents and siblings. At this time we will admit this patient . . . Plan: admit to PCU (Progressive Care Unit) on tele." The patient was admitted to the PCU on 3/16/23 at 2:57 PM as an observation patient, not an inpatient.

Physician orders for Morphine 2 MG (milligrams) IV (intravenous) push every 12 hours PRN (pro re nata, or as needed) were entered on 3/16/23 at 5:54 PM.

A nursing cognitive assessment on 3/17/23 at 7:36 AM read: "WDL" (within defined limits). A nursing assessment of 3/17/23 at 1:42 PM indicated the presence of pain ("complains of pain / discomfort.") It was documented at level "6" on a scale of 1 - 10 at this time. Morphine 2 MG IV push was given on 3/17/23 at 1:42 PM. An assessment at 2:00 PM on 3/17/23 read: "POSS (Pasero Opioid-Induced Sedation Scale) Score: 1 = awake and alert. . . . POSS level of sedation: acceptable." Thus, there would not be any limitations on the patient's ability to respond to questioning through this point in time on 3/17/23. There were no assessments from this point through discharge which indicated the presence of sedation or cognitive impairment, or any condition suggesting instability at discharge. A pain assessment at 2:00 PM on 3/17/23 read: "complains of pain / discomfort."

An assessment at 3:00 PM on 3/17/23 read: "Non-verbal indicators of pain/discomfort absent." This same finding was documented at 4:49 PM. A nursing cognitive assessment at this time read: "unchanged from my previous assessment." Thus, the patient would have been able to respond to a question. There was no evidence that either the 3:00 PM or 4:49 PM follow-up pain assessments were performed using a pain scale, which requires questioning to use.

A review of facility policy Pain Assessment and Management revealed the following: "Reassessment should occur after a medication intervention and typically carried out within 30-60 minutes after an intervention is given." A review of the policy continued: "If the patient verbally denies pain record this as '0' on the 0-10 pain intensity rating scale or record as denies pain. . . . The patient's self-report will be the primary means of determining pain." Since the patient was cognitively intact throughout the day, through 4:49 PM, the patient's pain level should have been assessed per the patient's self report. This was not done in any of the pain assessments after the 1:42 PM administration of Morphine ( 2:00 PM, 3:00 PM and 4:49 PM). Thus, the facility was in violation of the policy.

Per interview of the Risk Manager on 10/5/23 at 11:45 AM, the patient left the facility at least by 5:26 PM (taken out of system).

During an interview of the Administrator on 10/5/23 at approximately 2:00 PM she confirmed the preceding.