HospitalInspections.org

Based on record review and interview, the facility's registered nurse (RN) did not supervise and evaluate the nursing care of 1 of 1 patient (Patient #1) who presented in the emergency department (ED) on 3/14/16, in that the pain reassessment was not promptly conducted after pain medication administration as required.

Findings included:

Patient #1 presented in the ED on 3/4/16 at 2:15 AM for vaginal bleeding. At 4:17 AM "Fentanyl 25 mcg IVP" was administered for pain. The pain reassessment was not promptly conducted per protocol. The reassessment was conducted at 6:04 AM on 3/4/16, 1 hour and 47 minutes later.

In an interview on 5/10/16 at 6:08 PM via phone call in the presence of Personnel #2, Personnel #4 was informed of the above findings and confirmed the findings.

The facility policy "Pain Management in Adult Patients" reviewed 10/2013 required "A pain assessment will be performed...After each pharmacologic pain management intervention once sufficient time has elapsed for the treatment to reach peak effect."

Obtained on 5/13/16 at 10:06 AM at
"Fentanyl Injection - Clinical Pharmacology: The onset of action of fentanyl is almost immediate when the drug is given intravenously...The usual duration of action of the analgesic effect is 30 to 60 minutes after a single intravenous dose of up to 100 mcg..."