HospitalInspections.org

Based on document reviews and interviews, nursing staff failed to reevaluate a patients pain management needs and ensure pain assessments and interventions were completed in a timely manner according to standards of practice and physician orders in one of ten inpatient records reviewed (Patients #2).

Findings include:

Facility policy:

The Nursing Documentation Philosophy and Standards policy read, a qualified individual develops and documents in the medical record individualized plans of care for all inpatients that may include, but are not limited to the following: pain management.

The Inpatient Patient Care Guidelines policy read, the patient will be provided necessary medical care completed in a timely manner and with effective pain management techniques to cause as little discomfort as possible.

The Medication: Administration policy read, the RN (Registered Nurse) and LPN (Licensed Practical Nurse) may administer medication as ordered by the physician. Administration of pain medication per licensed independent practitioner's orders. Pain is assessed and treated per policy, Pain-Assessment and Treatment.

The Pain: Assessment and Treatment policy read, pain is treated as soon as possible. Monitoring and documenting pain for all patients occurs: after pain interventions and new reports of pain. Re-assessments are done in a timely manner, according to the patient need. The patient's response to pain intervention is documented within four hours following the intervention. If pain remains rated above the target goal, a reassessment of the treatment plan occurs. Notify physician of sudden changes in pain or unrelenting pain in previously controlled situations.

Pain Definitions listed were:

0 = No pain
1-4 = Mild
5-6 = Moderate
7-10 = Severe

1. Nursing staff did not ensure Patient #2's pain was reevaluated and managed according facility guidelines and physician orders.

a. Review of Patient #2's medical record revealed the patient was admitted to the facility on 4/15/19. According to the hospitalist's progress note, dated 4/16/19, the patient's home medications were restarted for the patient's chronic pain. According to the nursing past medical history documentation, dated 4/15/19 at 6:33 p.m., chronic pain was defined as pain that persisted 12 or more hours out of the day and had been present greater than six weeks. The patient's admitting nurse documented the patient's stated pain level goal was a zero on a numeric pain scale.

b. On 4/16/19 at 12:56 p.m. Registered Nurse (RN #6) documented in the Medication Administration Record (MAR), Patient #2 reported a pain level at a nine out of ten, which was considered severe intensity according to facility policy. RN #6 gave the patient 10 milligrams of scheduled oxycodone immediate release (a narcotic pain reliever). At 1:26 p.m., RN #6 reassessed the patient and documented the patient's reported pain level was at a five which was still higher than the patient's goal of zero.

The next pain assessment was not documented until four hours later, at 5:41 p.m. Patient #2's pain level increased from five to nine. Review of physician orders showed, the patient could have been administered a different narcotic pain reliever, Norco. The medication was ordered to be given every four hours for moderate level of pain, which according to the policy was defined as an intensity of five or six.

On 4/19/19 at 12:08 a.m., the patient's nurse documented on the MAR the patient was administered 10 mg of oxycodone IR (immediate release). Patient #2's reported pain level was documented as a 10 at his esophagus and chest. A reassessment was documented at 12:38 a.m., in which the patient's documented pain level was reported as a nine. The next pain assessment was not documented until 4 hours 30 minutes later, at 5:03 p.m. Patient #2's reported pain level was a 10. There was no evidence which showed how nursing staff managed the patient's pain between his scheduled pain medications.

On 4/19/19 at 1:10 p.m. and at 1:13 p.m., RN #8 documented a pain reassessment after both scheduled oxycodone IR and as needed Dilaudid (a narcotic to treat moderate to severe pain) were given. According to the reassessment documented on the MAR, dated 4/19/19-4/20/19, Patient #2 reported his pain was a seven out of ten. The next pain medication and assessment was not documented until eight hours later. The patient's night nurse documented at 9:34 p.m., Patient #2 reported his pain level was a nine.

According to the physician orders, the Dilaudid was ordered to be given every four hours as needed for pain. There was no documentation which showed if nursing staff attempted to administer the ordered pain medication or how the patient's pain was managed during the eight hour gap from 1:13 p.m. until 9:34 p.m.

On 4/23/19 at 12:30 p.m., RN #3 documented on the MAR, Patient #2's pain level was a nine after he was given oxycodone IR at 12:00 p.m., The next documented reassessment was not until 5:50 p.m., when the patient reported a higher pain level than the numeric scoring allowed. RN #3 documented the patient reported that his pain was at 11. There was no evidence as to why RN #3 did not administered ordered as needed Dilaudid which was available every 4 hours for severe pain.

c. On 8/7/19 at 3:27 p.m., an interview was conducted with RN #3. She said she provided nursing care to Patient #2 for more than one day, but was unable to remember the exact dates. A review of Patient #2's medical record was conducted.

RN #3 stated she remembered having a conversation with him about his pain reassessments but could not say the specific details of the conversation with the patient. She said if a patient's pain was at a seven, which she stated was high on the pain scale, she would ask the patient what she could do for them.

Upon exit, there was no documentation in Patient #2's medical record indicating RN #3 offered alternatives to manage the patient's pain. Additionally, there was no nursing care plan in the record for pain management which showed how nursing staff were going to achieve the patient's pain management goals.

RN #3 stated one of the first questions she would ask a patient would be about their pain. She said if the patient stated yes they were having pain, then she would ask the patient to describe the pain and the intensity. RN #3 said she would then ask the patient if they needed anything for the pain.

RN #3 said if the patient needed something for the pain, she would provide pain medications. RN #3 said, after the medication was given, she would reassess the patient to see if the medication worked.

RN #3 said when a patient was admitted, they were asked what their pain level goal was. RN #3 stated she would also ask the patient their goal with every physical assessment she conducted.

RN #3 stated, if an IV medication was given, the patient's pain should be reassessed within 15 minutes and with oral, within 30 minutes. She said this was done to see if the medication was working. RN #3 stated she learned about the reassessment times in nursing school.

d. On 8/8/19 at 10:26 a.m., an interview was conducted with the nurse manager (Manager #4) of the unit Patient #2 stayed in during his admission. The associate vice president of nursing (VP #5) was also interviewed.

Patient #2's medical record was reviewed. VP #5 stated Patient #2's pain reported pain goal was a zero.

A review of the medication administration record, dated 4/23/19, was conducted. Both confirmed Patient #2 was given Dilaudid at 9:42 a.m. for a reported pain level of nine. The reassessment was documented at 10:12 a.m. in which the patient pain score was a seven. The next pain medication given was oxycodone immediate release at 12:00 p.m., which the patient's pain level was reported at a higher score of nine. At 12:30 p.m., the next pain medication documented on the MAR was not until 6:00 p.m., 5 hours and 30 minutes later. According to the physician's orders, the Dilaudid could be given every four hours as needed.

Manager #4 stated she could not find another assessment between 12:30 and 6:00 p.m. VP #5 stated, a pain goal of zero could be unrealistic but if that was his goal, nursing staff was not meeting it. Both Manager #4 and VP #5 were unable to find a care plan for Patient #2's chronic pain issues. VP #5 stated the fact Patient #2 had pain should have triggered a care plan for him.