HospitalInspections.org

41127


Based on record review and interview, the facility failed to document interventions for pain management and/or failed to document reassessments following the administration of pain medications according to facility policy in 6 of 10 patients (Patients #1, 2, 4, 5, 7, 8) who reported pain out of a total universe of 10 medical records reviewed.

Findings include:

Review of facility policy #GN-037 titled, "Pain Management" approved 04/27/2020 revealed, "...II. PURPOSE: To establish guidelines for pain management, which include assessment, intervention, and documentation...III. GUIDELINES/PROCEDURES: A. Healthcare Professionals are expected to: 1. Assess patients' pain and inform of pain relief measures. 2. Acknowledge and respond to patients' report of pain. 3. Utilize evidence-based pain management techniques...IV. HEALTH CARE PROFESSIONAL'S RESPONSIBILITIES FOR PAIN MANAGEMENT...1. Patients are assessed for pain using a 0-10 scale or appropriate alternative tool for objective measurement...As a general guideline the pain severity indicator corresponds to the pain level: mild (1-3), moderate (4-7) and severe (8-10). 2. Assessment of any report of pain includes intensity, location, onset, a visual or physical assessment of the pain site, and the present pain medication regimen...4. After any pharmacological pain management intervention for unacceptable pain, pain scores are reassessed within two hours and documented...5. Non-pharmacological interventions can enhance the patient's sense of control and add to the effectiveness of the pharmacological interventions. They are not intended to replace analgesics, but to be used as an adjunct...It is the responsibility of the primary nurse to consider initiating these interventions and to assess their ongoing effectiveness..."

Review of facility policy #MR-005 titled, "Nursing - Patient Assessment/Reassessment" approved 09/24/2017 revealed, "...III. GUIDELINES/PROCEDURES...D. Ongoing patient assessment and interventions: all care given to a patient by any member of the interdisciplinary team is documented in the Patient Assessment Navigator..."

Patient #1

Patient #1's electronic medical record was reviewed on 9/8/2020 with Infomaticist A who confirmed the following:

Patient #1 was admitted to the facility on 5/28/2020 for progressive myelopathy (injury to the spinal cord due to severe compression.) Patient #1 had 3 surgeries during this hospitalization and was discharged from the Rehab unit on 7/24/2020.

In addition to PRN (as needed) pain medications Patient #1 received scheduled medications to relieve muscle spasms.

On 5/28/2020 at 9:37 PM the "Pain Observation" flowsheet revealed "Pain Score 9 (severe pain)" with a comment, "awaiting orders". "Pain Score" is documented 9 at 9:53 PM, 11:40 PM with no interventions documented.

On 5/29/2020 at 9:47 AM "Pain Score is documented as 9 (severe pain); described as "ongoing, continuous, not changed." Review of the electronic medication administration record (eMAR) revealed Patient #1 received oral PRN pain medications at 9:50 AM, 2:53 PM, 6:51 PM and intravenous pain medication at 10:40 PM. The Pain Assessments revealed assessments at 5:05 PM (6 hours after the 9:50 AM administration of PRN pain medication), 9:40 PM and 11:40 PM. There was no documented reassessments after the 2:53 PM, 6:51 PM or 10:40 PM administration of PRN pain medications.

On 6/1/2020 at 12:20 AM "Pain Score" is documented at "7" (moderate pain), at 12:49 it is documented as "9" (severe pain). The next reassessment was at 4:06 AM when an oral pain medication was administered. The next assessment is at 7:27 AM, 3.5 hours later with the "Pain Score" documented at "9". The next "Pain Assessment" was at 9:08 PM with "Pain Score" of 9. eMAR documents pain medication given at that time.

On 6/2/2020 the eMAR documents pain medication given at 9:30 AM for "Pain Score" of 9. The next reassessment of pain is at noon.

Patient #2

Patient #2's electronic medical record was reviewed on 09/08/2020 at 1:17 PM with RN Informaticist G who confirmed the following:

Patient #2 was admitted to the facility on 08/25/2020 for an elective, 2-stage back surgery. Patient #2 was transferred to the inpatient rehab unit on 09/03/2020 and was a current inpatient on the dates of the survey.

On 09/04/2020 at 7:44 AM, the "Pain Observation" flowsheet revealed, "Pain Score...10 (severe pain)." There were no interventions documented. The next pain assessment was documented over 6.75 hours later, at 2:26 PM.

At 2:26 PM, "Pain Score" is documented as "10 (severe pain)." There were no interventions documented. The next pain assessment was documented 1.75 hours later, at 4:15 PM.

At 4:15 PM, "Pain Score" is documented as "7 (moderate pain)." There were no interventions documented. The next pain assessment was documented nearly 4 hours later, at 8:05 PM.

On 09/05/2020 at 5:00 PM, the "Pain Observation" flowsheet revealed, "Total Nonverbal Pain...1." Patient #2 received a scheduled oral analgesic at 5:11 PM. There was no reassessment documented within 2 hours of the administration of pain medication per facility policy. The next pain assessment was documented nearly 4.5 hours later, at 9:45 PM.

On 09/06/2020 at 4:44 PM, the "Pain Observation" flowsheet revealed, "Total Nonverbal Pain...0." Patient #2 received a scheduled oral analgesic at 4:40 PM. There was no reassessment documented within 2 hours of the administration of pain medication per facility policy. The next pain assessment was documented over 4 hours later, at 9:06 PM.

At 9:06 PM, "Pain Score" is documented as "10 (severe pain)." Patient #2 received an oral analgesic at 9:05 PM. There was no reassessment documented within 2 hours of the administration of pain medication per facility policy. The next pain assessment was documented nearly 3 hours later, on 09/07/2020 at 12:03 AM.

On 09/07/2020 at 5:25 AM, the "Pain Observation" flowsheet revealed, "Pain Score...7 (moderate pain)." There were no interventions documented.

At 8:21 AM, "Pain Score" is documented as "5 (moderate pain)." Patient #2 received an oral analgesic at 8:18 AM. There was no reassessment documented within 2 hours of the administration of pain medication per facility policy. The next pain assessment was documented over 2.5 hours later, at 11:00 AM.

Patient #4:

Patient #4's electronic medical record was reviewed on 09/08/2020 with Registered Nurse (RN) Informaticist G who confirmed the following:

Patient #4 was admitted to the facility on 06/08/2020 for elective back and neck surgery. Patient #4 was transferred to the facility's rehab unit on 6/10/2020 and discharged on 6/26/2020.

On 06/11/2020 at 3:12 AM, the "Pain Observation" flowsheet revealed, "Pain Score...8 (severe pain)." There are no interventions documented. The next pain assessment is documented over 3 hours later, at 10:28 AM.

At 12:28 PM, "Pain Score" is documented as "6 (moderate pain)." "Clinical Progression" is documented as "Gradually worsening." "Pain Intervention(s)" revealed, "Medication (see eMAR) (Comment) scheduled." Upon review of Patient #4's medication administration report, there was no medication documented as given at or around 12:28 PM.

The next pain assessment is documented over 4 hours later, at 4:34 PM. "Pain Score" is documented as "7 (moderate pain)." There are no interventions documented. The next documented pain assessment is documented over 5 hours later, at 9:38 PM.

On 06/12/2020 at 8:41 PM, the "Pain Observation" flowsheet revealed, "Pain Score...4 (moderate pain)." Patient #4 received an oral analgesic at 8:42 PM. There was no reassessment documented within 2 hours of the administration of pain medication per facility policy. The next pain assessment was documented nearly 4.5 hours later, on 06/13/2020 at 1:06 AM.

On 06/14/2020 at 3:36 AM, the "Pain Observation" flowsheet revealed, "Pain Score...8 (severe pain)." Patient #4 received an oral analgesic at 3:36 AM. There was no reassessment documented within 2 hours of the administration of pain medication per facility policy. The next pain assessment was documented over 5 hours later, at 8:49 AM.

At 5:00 PM, "Pain Score" is documented as "8 (severe pain)." Patient #4 received 3 oral analgesics at 4:38 PM. There was no reassessment documented within 2 hours of the administration of pain medication per facility policy. The next pain assessment was documented over 4 hours later, at 9:04 PM.

On 06/15/2020 at 8:40 AM, the "Pain Observation" flowsheet revealed, "Pain Score...5 (moderate pain)." Patient #4 received an oral analgesic at 8:40 AM. There was no reassessment documented within 2 hours of the administration of pain medication per facility policy. The next pain assessment was documented nearly 8.5 hours later, at 5:06 PM.

At 7:45 PM, "Pain Score" is documented as "6 (moderate pain)." Patient #4 received a scheduled oral analgesic over 2.5 hours later, at 10:20 PM. There was no reassessment documented within 2 hours of the administration of pain medication per facility policy. The next pain assessment was documented nearly 10 hours after the administration of pain medication and over 12 hours after the last pain assessment, on 06/16/2020 at 8:16 AM.

On 06/16/2020 at 5:51 PM, the "Pain Observation" flowsheet revealed, "Pain Score...7 (moderate pain)." Patient #4 received an oral analgesic at 5:52 PM. There was no reassessment documented within 2 hours of the administration of pain medication per facility policy. The next pain assessment was documented over 3 hours later, at 9:00 PM.

At 9:00 PM, "Pain Score" is documented as "9 (severe pain)." Patient #4 received 2 scheduled oral analgesics at 9:24 PM. There was no reassessment documented within 2 hours of the administration of pain medication per facility policy. The next pain assessment was documented 6 hours later, on 06/17/2020 at 3:00 AM.

On 06/17/2020 at 8:21 AM, the "Pain Observation" flowsheet revealed, "Pain Score...10 (severe pain)." Patient #4 received 3 oral analgesics at 8:22 AM and a topical analgesic patch was applied at 8:23 AM. There was no reassessment documented within 2 hours of the administration of pain medication per facility policy. The next pain assessment was documented over 4 hours later, at 12:23 PM.

At 12:23 PM, "Pain Score" is documented as "7 (moderate pain)." There are no interventions documented. The next pain assessment is documented nearly 4 hours later, at 4:17 PM.

On 06/18/2020 at 8:23 AM, the "Pain Observation" flowsheet revealed, "Pain Score...5 (moderate pain)." Patient #4 received 2 oral analgesics and a topical analgesic patch was applied at 8:20 AM. There was no reassessment documented within 2 hours of the administration of pain medication per facility policy. The next pain assessment was documented nearly 3.5 hours later, at 11:50 AM.

At 11:50 AM, "Pain Score" is documented as "9 (severe pain)." Patient #4 received a oral analgesic at 11:54 AM. There was no reassessment documented within 2 hours of the administration of pain medication per facility policy. The next pain assessment was documented over 3 hours later, at 3:00 PM.

At 8:36 PM, "Pain Score" is documented as "7 (moderate pain)." Patient #4 received 2 scheduled oral analgesics at 8:36 PM. There was no reassessment documented within 2 hours of the administration of pain medication per facility policy. The next pain assessment was documented nearly 13.5 hours later, on 06/19/2020 at 10:00 AM.

On 06/19/2020 at 4:57 PM, the "Pain Observation" flowsheet revealed, "Pain Score...6 (moderate pain)." Patient #4 received 2 oral analgesics at 4:57 PM. There was no reassessment documented within 2 hours of the administration of pain medication per facility policy. The next pain assessment was documented over 4.5 hours later, at 9:31 PM.

On 06/20/2020 at 5:00 PM, the "Pain Observation" flowsheet revealed, "Pain Score...3 (mild pain)." Patient #4 received 2 scheduled oral analgesics at 5:01 PM. There was no reassessment documented within 2 hours of the administration of pain medication per facility policy. The next pain assessment was documented over 4.5 hours later, at 9:27 PM.

On 06/21/2020 at 9:13 AM, the "Pain Observation" flowsheet revealed, "Pain Score...3 (mild pain)." Patient #4 received 2 scheduled oral analgesics at 9:14 AM. There was no reassessment documented within 2 hours of the administration of pain medication per facility policy. The next pain assessment was documented nearly 8 hours later, at 5:00 PM.

At 8:45 PM, "Pain Score" is documented as "2 (mild pain)." Patient #4 received 2 scheduled oral analgesics one hour later at 9:43 PM. There was no reassessment documented within 2 hours of the administration of pain medication per facility policy. The next pain assessment was documented nearly 4.5 hours after the previous pain assessment and 3.5 hours after the administration of pain medication, on 06/22/2020 at 1:15 AM.

On 06/22/2020 at 8:11 AM, the "Pain Observation" flowsheet revealed, "Pain Score...2 (mild pain)." Patient #4 received 2 scheduled oral analgesics at 8:09 AM. There was no reassessment documented within 2 hours of the administration of pain medication per facility policy. The next pain assessment was documented nearly 4 hours later, at 12:17 PM.

At 4:20 PM, "Pain Score" is documented as "5 (moderate pain)." Patient #4 received 2 scheduled oral analgesics at 4:41 PM. There was no reassessment documented within 2 hours of the administration of pain medication per facility policy. The next pain assessment was documented over 4.5 hours later, at 8:59 PM.

At 8:59 PM, "Pain Score" is documented as "3 (mild pain)." Patient #4 received 2 scheduled oral analgesics at 8:59 PM. There was no reassessment documented within 2 hours of the administration of pain medication per facility policy. The next pain assessment was documented nearly 6 hours later, on 06/23/2020 at 2:51 AM.

On 06/23/2020 at 12:26 PM, the "Pain Observation" flowsheet revealed, "Pain Score...3 (mild pain)." Patient #4 received an oral analgesic at 12:26 PM. There was no reassessment documented within 2 hours of the administration of pain medication per facility policy. The next pain assessment was documented 8.5 hours later, at 8:58 PM.

On 06/24/2020 at 12:29 PM, the "Pain Observation" flowsheet revealed, "Pain Score...1 (mild pain)." Patient #4 received an oral analgesic at 12:30 PM. There was no reassessment documented within 2 hours of the administration of pain medication per facility policy. The next pain assessment was documented nearly 6.5 hours later, at 7:02 PM.

Patient #5

Patient #5's electronic medical record was reviewed on 09/09/2020 at 7:19 AM with RN Informaticist G who confirmed the following:

Patient #5 was admitted to the facility on 06/06/2020 following a motorcycle accident. Patient #5 underwent neck surgery on 06/09/2020 and was discharged the following day, 06/10/2020.

On 06/07/2020 at 11:14 AM, the "Pain Observation" flowsheet revealed, "Pain Score...9 (severe pain)." Patient #5 received an intravenous pain medication at 11:14 AM. There was no reassessment documented within 2 hours of the administration of pain medication per facility policy. The next pain assessment was documented nearly 3.5 hours later, at 2:47 PM.

On 06/08/2020 at 12:28 AM, the "Pain Observation" flowsheet revealed, "Pain Score...8 (severe pain)." There were no interventions documented. The next documented pain assessment was over 7.5 hours later, at 8:00 AM.

Patient #7

Patient #7's electronic medical record was reviewed on 09/09/2020 at 8:16 AM with RN Informaticist G who confirmed the following:

Patient #7 was admitted to the facility on 07/26/2020 following a motorcycle accident. Patient #7 underwent neck surgery on 07/28/2020 and was discharged the following day, 07/29/2020.

On 07/26/2020 at 3:45 PM, the "Pain Observation" flowsheet revealed, "Pain Score...8 (severe pain)." Patient #7 received an oral analgesic at 3:38 PM. There was no reassessment documented within 2 hours of the administration of pain medication per facility policy. The next pain assessment was documented nearly 4.5 hours later, at 8:11 PM.

During an inteview on 09/09/2020 at 7:15 AM with Quality Coordinator C, when asked about the expectation for pain reassessments following scheduled pain medications, Quality Coordinator C stated, "I would expect to see them (reassessments) within 2 hours for both scheduled and PRN (as needed) medications. I would not expect to see documentation of reassessments after non-pharmacological interventions. I will check with [Manager D] to see if she can find the reassessments."

At 9:25 AM, Quality Coordinator C stated, "I heard back from [Manager D]. Yes, it appears some reassessments are missing. Sounds like [he/she] agrees with you."

At 10:02 AM, when asked to verify that pain reassessments were not consistently documented every 2 hours per facility policy for patients #2, 4, 5, and 7, Quality Coordinator C stated, "Yes." When asked if the expectation is that both pharmacologic and non-pharmacologic interventions are to be documented in the pain observation flowsheet, Manager D stated, "Yes, I agree that any interventions should be documented there."

Patient # 8

Patient #8's electronic medical record was reviewed on 9/9/2020 with Infomaticist A who confirmed the following:

Patient #8 was admitted to the facility on 5/5/2020 for a removal of cervical hardware and a cervical fusion. He was discharged from the Rehab unit at the hospital on 5/12/2020.

On 5/7/2020 at 6:10 AM "Pain Observation" flowsheet revealed "Pain Score 8" (severe pain) and the eMAR documents an intramuscular pain medication was administered. The next pain assessment is documented at 12:04 PM with a "Pain Score 8". The eMAR documents an oral pain medication was administered. The next pain assessment is documented at 4:16 PM with a "Pain Score 8."

On 5/10/2020 at 4:12 AM the eMAR documents an oral pain medication was administered for a "Pain Score" of 4. The next documented "Pain Assessment" is at 8:33 AM.