HospitalInspections.org

Based on record review, and interview, the hospital's nursing service did not ensure that drugs had been administered as ordered by the physician, and in accordance of accepted standards of practice, in that, 1 of 1 patient (Patient #19) did not receive pain medication after being ordered on 11/30/12 by the physician (Personnel #18) for Patient #19's abdominal pain.

Findings included:

The medical record showed that Patient #19 was admitted through the Emergency Department (ED) at 8:30 PM on 11/29/12, with a chief complaint of "abdominal pain, inflamed colon, continues to get worse." Patient #19 had a history of Lap Band procedure in August 2010, and she had not had a bowel movement in 10 days. Her course of care in the ED included Labs, X-rays, EKG (electrocardiogram), all essentially normal. Patient #19 also had an Acute Abdomen Series which noted findings of "a lap band is in position...there is increased gas within the colon perhaps from aerophagia...there is no small bowel dilatation to suggest intestinal obstruction...there is no mass or visceromegaly." She also received a CT (computerized tomography) of the Abdomen and Pelvis with Contrast, with findings of "small amount of free intraperitoneal fluid...this could be related to the abnormal small bowel for infectious or inflammatory fluid..." IV (intravenous) fluids given (Normal Saline)...Zofran (prevents nausea & vomiting) given, 4 mg (milligrams) IV, and Protonix (suppresses gastric secretions) given 40 mg. IV. The ED Physician (Personnel #14) documented that "the patient complains of moderate abdominal pain," and ordered to "Admit to Medicine Service...Diagnosis: Abdominal pain, Constipation, Nausea, and partial SBO (Small Bowel Obstruction). ED Nurses Notes documented that "patient reports pain level as 5/10 (with 10 being the greatest pain). Patient #19 had no orders for pain medication while in the ED, and none were ordered when admitted to the hospital.

At 5:02 AM on 11/30/12, Patient #19 was admitted as an inpatient to the Heart & Vascular Care (HVC) Unit, with orders for IV fluids, IV antibiotics, and NPO (nothing by mouth). Her nursing pain assessment by the registered nurse (Personnel #12), at 8:00 AM was "verbalized as a 7, with an aching in her abdomen." The nursing intervention at that time was to re-position the patient, as no pain medication was ordered. Personnel #12 documented the following:
11:35 AM: "spoke with Internal Medicine Physician (Personnel #16)...explained patient is having severe abdominal pain..."
15:20 PM: "Gastroenterologist Physician (Personnel #18) on floor..."

Physician's Orders (Personnel #18), at 15:50 PM for pain medication, Dilaudid.

At 15:53 PM, the Medication Administration Record documented that the Pharmacy had put the order entry into the system for Dilaudid 1 mg IV every 6 hours, as needed for pain. However, this pain medication was not charted as ever given to the patient.
Patient #19 left the hospital AMA (Against Medical Advice), at 17:20 PM, and had not received pain medication that had been ordered 1 and 1/2 hours earlier.

In a telephone interview at 10:35 AM on 4/24/13 with the registered nurse (Personnel #12), she was asked why Patient #19 did not get pain medication, and she stated that "she had reported that the patient was in pain, but the primary physician (Personnel #16) wanted to get consults from the gastroenterologist (Personal #18), about giving pain medication as it can cause constipation, which was already a major issue with the patient. When asked if she had given Patient #19 IV pain medication, after it had been ordered by the gastroenterologist at 15:20 PM, she said "no."

The hospital's "Pain Management " policy, last revised 8/03/11, noted that "Pain/Pain management is assessed and documented in all patients...managed in a timely uniform manner..."