HospitalInspections.org

Based on hospital policy reviews, medical record reviews, and staff interviews, the nursing staff failed to ensure ongoing reassessment of a patient's pain intensity and response to pain management interventions for 4 of 10 closed emergency department records reviewed (#8, #5, #10, #4).

The findings include:

Review of current hospital policy "Medication Administration" reviewed 10/09, revealed "...5. For PRN (as needed), document patient response within one hour (exception: 2 hours for anti-pyretics). ..."

Review of current hospital policy "Pain Assessment and Management" reviewed/revised 04/2010, revealed "...C. Monitoring Effectiveness of Interventions 1. Pain intensity is evaluated after each pain management intervention once a sufficient time has elapsed for treatment to reach peak effect. ...3. ...b. Pain intensity is to be documented on the MAR (medication administration record) following PRN pain medication. ..."

1. Closed dedicated emergency department (DED) record review for Patient #8 revealed a 35 year old female who presented to the hospital's DED on 07/01/2011 at 0017 for complaints of flank pain. The patient was subsequently treated and discharged on 07/01/2011 at 0542 with a diagnosis of flank pain secondary to kidney stone. Review of a MAR dated 07/01/2011 revealed documentation by a nurse the patient received the following medication(s) for pain per physician's orders: Dilaudid (narcotic) 1 mg (milligram) IV (intravenous) Push at 0136, 0155 and Morphine (narcotic) 4 mg IV push at 0231, 0302, and 0441. Record review revealed no available documentation of a reassessment performed by the nursing staff, of the patient's pain intensity and response to the pain management intervention within one hour after each administration.

Interview with DED nursing management staff on 07/07/2011 at 1045 revealed nursing staff are expected to reassess a patient's response to a pain intervention within 15-30 minutes after administration for IV medications and 45 minutes to 1 hour after administration for oral medications. Interview revealed the nursing staff are to document the patient's pain intensity and response to pain interventions in the electronic medical record using a numerical (0-10) or FLACC (Face, Legs, Activity, Cry, Consolability) scale, depending on age. Interview revealed all medications administered in the DED are considered PRN medications. Interview confirmed there was no available documentation of the nursing staff's reassessment of Patient #8's pain intensity and response after the administration of Dilaudid on 07/01/2011 at 0136, 0155 and Morphine at 0231, 0302, and 0441. Interview confirmed the nursing staff failed to follow hospital policy.

2. Closed DED record review for Patient #5 revealed a 63 year old male who presented to the hospital's DED on 05/14/2011 at 2325 for complaints of abdominal pain. The patient was subsequently treated and admitted to an inpatient unit on 05/15/2011 at 0448 with a diagnosis of abdominal pain and partial small bowel obstruction. Review of a MAR dated 05/15/2011 revealed documentation by a nurse the patient received the following medication(s) for pain per physician's orders: Dilaudid 1 mg IV Push at 0133, 0208, 0238 and 0427. Record review revealed no available documentation of a reassessment performed by the nursing staff, of the patient's pain intensity and response to the pain management intervention within one hour after each administration.
Interview with DED nursing management staff on 07/07/2011 at 1045 revealed nursing staff are expected to reassess a patient's response to a pain intervention within 15-30 minutes after administration for IV medications and 45 minutes to 1 hour after administration for oral medications. Interview revealed the nursing staff are to document the patient's pain intensity and response to pain interventions in the electronic medical record using a numerical (0-10) or FLACC (Face, Legs, Activity, Cry, Consolability) scale depending on age. Interview revealed all medications administered in the DED are considered PRN medications. Interview confirmed there was no available documentation of the nursing staff's reassessment of Patient #5's pain intensity and response after the administration of Dilaudid on 05/15/2011 at 0133, 0208, 0238 and 0427. Interview confirmed the nursing staff failed to follow hospital policy.
3. Closed DED record review for Patient #10 revealed a 46 year old female who presented to the hospital's DED on 07/04/2011 at 1655 for complaints of pain secondary to a fall. The patient was subsequently treated and discharged on 07/04/2011 at 2109 with a diagnosis of musculoskeletal chest pain and left ankle sprain. Review of a MAR dated 07/04/2011 revealed documentation by a nurse the patient received the following medication(s) for pain per physician's orders: Hydrocodone-acetaminophen (narcotic) 5-325 mg tablet by mouth at 2004. Record review revealed no available documentation of a reassessment performed by the nursing staff, of the patient's pain intensity and response to the pain management intervention within one hour after administration.
Interview with DED nursing management staff on 07/07/2011 at 1045 revealed nursing staff are expected to reassess a patient's response to a pain intervention within 15-30 minutes after administration for IV medications and 45 minutes to 1 hour after administration for oral medications. Interview revealed the nursing staff are to document the patient's pain intensity and response to pain interventions in the electronic medical record using a numerical (0-10) or FLACC (Face, Legs, Activity, Cry, Consolability) scale depending on age. Interview revealed all medications administered in the DED are considered PRN medications. Interview confirmed there was no available documentation of the nursing staff's reassessment of Patient #10's pain intensity and response after the administration of Hydrocodone-acetaminophen on 07/04/2011 at 2004. Interview confirmed the nursing staff failed to follow hospital policy.
4. Closed DED record review for Patient #4 revealed a 50 year old male who presented to the hospital's DED on 05/14/2011 at 2321 for complaints of pain secondary to a fall. The patient was subsequently treated and discharged on 05/15/2011 at 0415 with a diagnosis of possible fracture of the left knee and right lateral malleolus on the ankle, versus sprain. Review of a MAR dated 05/15/2011 revealed documentation by a nurse the patient received the following medication(s) for pain per physician's orders: Hydrocodone-acetaminophen 5-325 mg tablet by mouth at 0117. Record review revealed no available documentation of a reassessment performed by the nursing staff of the patient's pain intensity and response to the pain management intervention within one hour after administration.
Interview with DED nursing management staff on 07/07/2011 at 1045 revealed nursing staff are expected to reassess a patient's response to a pain intervention within 15-30 minutes after administration for IV medications and 45 minutes to 1 hour after administration for oral medications. Interview revealed the nursing staff are to document the patient's pain intensity and response to pain interventions in the electronic medical record using a numerical (0-10) or FLACC (Face, Legs, Activity, Cry, Consolability) scale depending on age. Interview revealed all medications administered in the DED are considered PRN medications. Interview confirmed there was no available documentation of the nursing staff's reassessment of Patient #4's pain intensity and response after the administration of Hydrocodone-acetaminophen on 05/14/2011 at 0117. Interview confirmed the nursing staff failed to follow hospital policy.
NC00073390