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Based on document review, and staff interview, the agency failed to ensure that Patient #1, one (1) of six (6) patients reviewed, participated in her Plan of Care (POC) related to pain management.

Findings include:

Record review for Patient #1 revealed no documented evidence of patient participation in her POC related to pain management. During admission on 11/22/09 Patient #1 told the admitting nurse that because of pain from an automobile accident in 2004 she took Percocets by mouth every six (6) hours and that she took a sleeping pill nightly. Patient #1 was asked by the admitting nurse if she was currently in acute pain and did she have chronic pain. The patient answered "Yes." The admitting nurse documented that the acute pain was related to the patient's kidney.

There was no documented evidence of a careplan to show that the Registered Nurse (RN) was managing the patient's complaints of pain. The RN had a list of the patient's admission medications and the patient's history of pain, but failed to develope an action plan to keep this patient pain free.

Documented evidence showed that the patient was admitted with a diagnosis of Pyleonephritis, but did not receive any pain medication for two (2) days. On day three (3) she was given two (2) Darvocet on two (2) different occasions for complaints of pain. On the 7th day the patient's physician ordered Ambien for sleep.

On 11/23/09 Patient #1 told staff that her pain level was three (3) on a scale of one to five (1-5). There was no documented evidence that she was given any pain medication. On 11/24/09 Patient #1 told staff that her level of pain was four (4) on a scale of one to five (1-5).

During an interview on 01/28/10 at 4:00 p.m. RN #2 stated that when a patient tells staff that they are in pain they are given Darvocet from the floor stock. When asked if the Darvocet didn't work for severe pain what would they do? The nurse hesitated. Then when asked if they would call the patient's physician RN #2 stated, "Yes, we would call him but we all know what they would say."

On 01/28/10 at 3:10 p.m. and 4:15 p.m., both RN #1 and RN #2 were interviewed and both RNs stated that a pain level of four (4) warranted severe pain. However, this patient was only given the standing order of Darvocet as a pain reliever. There was no documented evidence of a physician's order for a pain medication other than the Darvocet.

Based on staff interview and document review, the facility failed to ensure that the registered nurse (RN) supervised and evaluated the nursing care for each patient.

Findings include:

In one of one patients the care was not evaluated by a RN. The patient told the admitting nurse, because of the pain from an automobile accident in 2004, she took Percocets by mouth 4 times a day. The patient also took a sleeping pill nightly.

There was no care plan in which the RN was managing this patient's pain. The RN had the admission medications, the patient's history and no action plan was developed to keep this patient pain free. This patient was allowed to go without pain medication for two complete days with a diagnosis of Pyleonephritis. On the third day, she was only given 2 darvocets times 2. The patient was given a sleeping pill on the 7th day.

The patient stated on 11-23-09 her pain was a 3 on a scale of 1-5 and was given no pain medication. On 11-24-09, the patient stated she had pain of 4. On 01-28-10 at 3:10 and 4:15, both RNs interviewed stated a 4 warranted severe pain. However, this patient was given the standing order of Darvocet. Both RNs were asked how did the RN know their patient was hurting and if their LPNs had provided any medications for the patients. They both stated, it was according to who the LPNs were. Some tell them if the patient has a problem and sometimes they do not know until report at 7:00 p.m. that night. When asked how can they take care of their patients that way, they both said, they can look at the veriscan and see if they have gotten anything for pain but sometimes they do not know until the next shift comes on. LPNs are not licensed to assess pain.

Based on staff interview and record review, the facility failed to develop and keep current a nursing Plan of Care (POC) for each patient.

Findings include:

Based on record review and staff interview, the facility failed to ensure that Registered Nurses (RNs) developed care plans with the patient involvement, failed to ensure that RNs were following through on assessing pain levels and administering pain medication as needed, communicating with the Licensed Practical Nurses (LPNs) in regard to their inability to assess pain, to notify the RN when pain is present and medication is given or needed in 4 of 4 patients, Patient #1, #2, #3, and #4.

Findings include:

In one of one patients reviewed the patient was getting IV dilaudid and the chart reflected a pain scale of 1. (1 being the lowest level of pain)

In 3of 4 charts all intakes and outputs are not documented. On January 28, 2010, in 3 interviews with staff on the 5th floor, they stated intakes and outputs are done on everyone since it is a renal floor. There does not have to be an order it is protocol.

In document review, in 4 of 4 charts, the person looking at the patient and assessing if pain medication worked is a LPN, who is not licensed to assess. The Registered Nurses interviewed on January 28, 2010, stated often they do not know what the LPNs are doing until report time at 7:00 PM. That is not supervision by a registered nurse.

Cross Refer to A395 for the facility's failure to develop and keep a current POC on patients.

Record review revealed no documented evidence of a POC reflecting a need for Percocet or additional pain medication for Pyleonephritis. Intake and output was not charted on this and other patients in which record review was performed.