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Based on policy and procedure review, medical record review, and patient and staff interviews, the nursing staff failed to verify PCA (Patient Controlled Analgesia) pump settings and usage at change of shift in 2 of 2 patients receiving PCA (Patients #10 and #12), failed to assess (Patient #11) and treat a patients pain in 1 of 7 medical records reviewed and failed to administer Nitroglycerin ointment according to the physician order for 1 of 7 patients (Patient #1).

The findings included:

1. Review on 01/11/2018 of the policy and procedure "Patient Controlled Analgesia (PCA) Intravenous/Subcutaneous and Continuous Infusion Analgesia" (Review date 02/15/2017) revealed "... VI. Documentation A. ...2. Pump settings including second licensed person verification with initiation, change in program or medication and at hand-off/shift change. ..."

A. Open medical record review on 01/09/2018 of Patient #10 revealed he was admitted on 01/08/2018 with a diagnosis of atypical chest pain, Glioblastoma (cancerous brain tumor), sickle cell disease and seizure disorder. Review revealed a physician order dated 01/08/2018 at 1916 for a Morphine Sulfate (intravenous pain medication) PCA, Loading Dose 0 mg (milligram), Patient Bolus Dose 1 mg, Lockout Interval 15 minutes, and Basal (continuous infusion) Rate 0mg/hr (hour). Review of the "Pain Monitoring" PCA flow sheet in the Electronic Medical Record (EMR) revealed no documented dual license signoff on 01/09/2018 at 0700 (day shift) shift change. Review revealed no evidence a PCA pump setting check with second license verification occurred at hand-off/shift change.

Interview on 01/09/2018 at 1525 with RN #12 revealed she was caring for Patient #10. Interview revealed PCA settings should have been checked at change of shift with a two nurse (on-coming and off-going) verification and sign off. Interview with RN #12 revealed "I typically do not document" the PCA setting verification on the flow sheet. Continued interview revealed the settings were verified by RN #12 and the oncoming nurse at shift report, but, there was no way to validate a PCA setting verification occurred because there was no documentation.

Interview on 01/09/2018 at 1530 with AS (Administrative Staff) #13 revealed "staff should" have documented PCA setting verification at shift change on the PCA flow sheet or in a note at shift change. Interview revealed failure to document the settings could potentially make identifying possible diversion difficult. AS #13 stated, "In the past, the facility had to perform random drug tests on several shifts of staff due to inaccurate narcotic counts and failure to document and or verify pain medicine administration. Interview confirmed policy was not followed.

B. Open medical record review on 01/11/2018 of Patient #12 revealed she was admitted on 01/03/2018 with a diagnosis of nausea and vomiting, breast cancer, hypocalcemia and right thigh pain. Review revealed a physician order dated 01/09/2018 at 1045 for a Morphine Sulfate (intravenous pain medication) PCA, Loading Dose 0, Patient Bolus Dose 2 mg, Lockout Interval 10 minutes, and Basal (continuous infusion) Rate 2mg/hr. Review of the "Pain Monitoring" PCA flow sheet in the EMR revealed no documented dual license signoff on 01/09/2018 at 1900 (night shift ) shift change, no documented dual sign off on 01/10/2018 at 1900 shift change and no dual license sign off on 01/11/2018 at 0700 (day shift) shift change. Review revealed no evidence a PCA pump setting check with second license verification occurred at hand-off/shift change.

Interview on 01/09/2018 at 1525 with RN #12 PCA settings should have been checked at change of shift with a two nurse (on-coming and off-going) verification and sign off. Interview with RN #12 revealed "I typically do not document" the PCA setting verification on the flow sheet. Continued interview revealed there was no way to validate a PCA setting verification occurred because there was no documentation.

Interview on 01/09/2018 at 1530 with AS (Administrative Staff) #13 revealed "staff should" have documented PCA setting verification at shift change on the PCA flow sheet or in a note at shift change. Interview revealed failure to document the settings could potentially make identifying possible diversion difficult. AS #13 stated, "In the past, the facility had to perform random drug tests on several shifts of staff due to inaccurate narcotic counts and failure to document and or verify pain medicine administration. Interview confirmed policy was not followed.

2. Review on 01/09/2018 of the policy "Pain Assessment and Management" (reviewed October 4, 2017) revealed, "...B. Pain assessment/reassessment V. ... 1. ...a. The evaluation for the presence of pain occurs twice within a 24-hour day (7a [sic]-7pm & 7pm-7am) and as indicated by the patient's plan of care/clinical situation. .. VII. ...Comfort/tolerable Level of Pain- Level that allows the patient to participate in care and comfortably perform activities that are important to him/her. ...."

Open medical record review on 01/09/2018 of Patient #11 revealed a 76 year old female patient admitted on 01/03/2018 with CAP (community acquired pneumonia). Review revealed an order dated 01/03/2018 at 1739 for "Acetaminophen (Tylenol) 650 mg suppository rectal every 6 hours for fever." Review of an order dated 01/09/2018 at 1357 revealed, "Acetaminophen 650 tablet oral every 6 hours as needed for moderate pain, headaches, fever," and an order dated 01/09/2018 at 1357 for "Acetaminophen 650 suppository rectal every 6 hours as needed for moderate pain, headaches, fever." Continued review revealed an order dated 01/08/2018 at 0933 for "Oxycodone HCL (pain medicine) immediate release tablet 5 mg oral by mouth every 4 hours as needed for Moderate Pain, Severe Pain." Review revealed no documented attempts by nursing to contact the physician group regarding pain or documented any progress note regarding rationale for not providing pain medication for pain management.

Review of the Pain
Assessment" flow sheet revealed:
Date: Time: Pain Level: Pain Intervention:
01/03/2018 1239 10 (high pain) none documented/no pain med
1245 10 none documented/no pain med
1652 9 (High pain) none documented/no pain med
1750 10 none documented/no pain med

01/05/2018 1040 10 none documented/no pain med
1145 5 (moderate pain) none documented/no pain med

01/06/2018 no pain assessment documented at least every shift
01/07/2018 no pain assessments documented at least every shift

01/09/2018 1416 10 Oxycodone 5mg at 1416 (given when RN notified by surveyor)
1516 8

Review revealed Patient #11's pain was not consistently assessed or treated per the policy.

Interview on 01/09/2018 with Patient #11 and a family member revealed she was admitted with pneumonia and because she could not walk. Interview revealed Patient #11 did not feel her pain was well managed and Patient #11 had refused therapy due to pain and discomfort. Interview revealed, at the time of interview Patient #11 stated a pain level of 10 (high). Interview revealed her nurse had not asked her about pain or provided pain medicine at the time of the interview. Continued interview revealed Patient #11 received Tylenol for pain once on 01/08/2018 (the day prior) until the time of interview.

Interview on 01/09/2018 at 1345 with RN #14 revealed she was caring for Patient #11. Interview revealed she was not aware that the patient was in pain, but, would assess Patient #11 and provide treatment. Continued interview revealed RN #14 had seen the patient, but, Patient #11's pain had not been assessed or documented at the time of the interview. Interview revealed pain assessments should have occurred each shift and as needed.



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3. Closed medical record review on 01/08 - 11/2018, of Patient #1 revealed a 70 year old male admitted with Sepsis (potentially life threatening severe infection) secondary to Cellulitis (an accumulation of fluids and bacteria in the tissues beneath the skin) of the Left Foot with Dry Gangrene (death of soft tissues due to obstructed circulation) of the Left Great Toe. Review revealed Patient #1 had multiple medical problems including a long history of ESRD (end stage renal disease) on HD (hemodialysis), left great toe gangrene, prostate cancer S/P (status post) radiation and cardiac tamponade (potentially life-threatening compression of the heart causing inadequate blood flow to vital organs) in 2014. On 11/14/2017, an X-ray of left foot revealed stable appearance, no osteomyelitis (infection through to the bone). Record review revealed Patient #1 underwent a surgical Below the Knee Amputation on 11/28/2017 performed by MD #2.

Closed medical record revealed the following dates where Nursing staff failed to follow the order for 2% Nitroglycerin ointment 0.5 inch to be applied to the top of left foot twice a day. Original order written 11/14/2017at 1150 then reordered post-op on 11/28/2017 at 1604.
Date Time Application site
- 11/21/2017 2058 left arm
- 11/23/2017 0817 abdominal tissue
- 11/23/2017 2049 chest
- 11/24/2017 2012 chest
- 11/25/2017 1208 chest
- 11/27/2017 0844 chest
- 11/28/2017 2207 left anterior thigh
- 11/29/2017 0818 left quadriceps
- 11/30/2017 0926 left quadriceps
- 11/30/2017 2009 right arm
- 12/01/2017 1011 left quadriceps
- 12/01/2017 2225 left deltoid
- 12/02/2017 0837 left quadriceps
- 12/02/2017 2122 chest
- 12/03/2017 0959 chest
- 12/03/2017 2157 chest
- 12/04/2017 2114 chest
- 12/06/2017 1037 other
- 12/08/2017 0831 chest
- 12/08/2017 2039 chest
- 12/09/2017 0924 chest


Interview on 01/09/2017 at 1300 revealed RN #6 stated, policy is "once a patient goes to surgery, all medication orders must be entered into the computer again." RN #6 stated, "the nitroglycerin order should have been clarified with the doctor, because the patient no longer had a foot."

A telephone interview with MD #2 was conducted on 01/11/2018 at 1053 regarding the care of Patient #1. Patient #1 had many medication orders including one for 2% Nitroglycerin ointment 0.5 inch to be applied to the top of left foot twice a day. The Nitroglycerin ointment was used as a vasodilator in this case to aid in increasing the circulation toward the left foot. The interview with MD #2 revealed, on 11/28/2017 at 1604, "I inadvertently reordered all of his meds that were ordered pre-operatively. With regards to this order (of Nitroglycerin applied to the top of left foot), I would have expected nursing to obtain clarification of this order. If Nursing had called me regarding this order, I would have discontinued the order."

A telephone interview with RN #4 was conducted on 01/11/2018 at 1150. RN #4 stated, "I cannot reflect on why I would apply the Nitroglycerin ointment to the chest when the order stated to apply to the top of the left foot."

A telephone interview with RN #5 was conducted on 01/11/2018 at 1210. The closed medical record was discussed with RN#5 (who applied ointment to right arm 11/30). RN #5 could not recall the rationale for not following the physician order as it was written.

NC00133200, NC00134187, NC00134215