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Based on policy review, clinical record review and interview it was determined the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5). This failure affected 6 of 7 sampled patients (Patient #1, #2, #3, #5, #6 and #7) as evidenced by failure to assess pain as specified in the facility policies and procedures and failure to follow prescription parameters for pain management.


The findings included:



Facility policy titled "Pain Management" revised 04/30/18 documents "To ensure effective pain management for the patients and to provide interdisciplinary direction to all staff members involved in the care of the patients experiencing pain.
The pain intensity and pain relief, as reported by the patient using the pain scale, will be assessed and documented:
On admission, at least every shift, with each new report of pain and when an intervention or treatment to relieve pain is provided. Pain assessments, reassessments, management and effects of treatment will be documented in the electronic medical record.


Interviews conducted with Patient #2 and Patient #3 conducted on 06/19/18 at 10:21 AM and 1:32 PM, respectively, revealed concerns regarding nursing care related to pain management.


Clinical record reviews conducted on 06/19/18 and 06/20/18 revealed the following:


1) Physician's Orders for Patient #1 dated 06/18/18 documents Percocet 5/325 milligram (mg) every four hours as needed for pain level 4-7 and Dilaudid 1 mg every three hours as needed for pain level 8-10.

Review of the Medication Administration Records and Assessment and Reassessments documentation indicates the facility staff administered pain medication with disregard to pain level parameters. Patient #1 received Dilaudid 1 mg on 06/18/18 at 1:32 AM for a pain level of 4. The record provides no documentation as to why the parameters were not followed. Furthermore, on 06/19/18 at 7:48 AM Patient #1 reported a pain level of 10, the interventions noted medicated. Medication Administration Record indicates the patient was medicated an hour later, at 8:56 AM with scheduled medication OxyContin.



2) Physician's Orders for Patient #2 dated 06/18/18 documents Percocet 10/325 milligram (mg) every three hours as needed for moderate pain level 4-7 and Dilaudid 1 mg every three hours as needed for severe pain level 8-10.

Review of the Mediation Administration Records and Assessment and Reassessments documentation indicates the facility staff did not conduct a pain assessment and administered pain medication with disregard to pain level parameters.
Patient #2 received Dilaudid on 06/19/18 at 2:33 AM. There is no evidence of a pain assessment prior to the administration of the drug. Furthermore, Patient #2 received Percocet 10 mg on 06/19/18 at 7:49 AM for a pain level of 10 and on 06/19/18 at 3:47 PM for a pain level of 8. The record has no explanation as to why the deviation from the prescription parameters.



3) Physician's Orders for Patient #3 dated 06/18/18 documents Dilaudid 1 mg every three hours as needed for severe pain level 8-10.
Review of the Medication Administration Records and Assessment and Reassessments documentation indicates the patient received Dilaudid 1 mg on 06/19/18 at 6:03 AM and there is no evidence of pain assessment prior to the administration.



4) Physician's Orders for Patient #5 dated 05/07/18 documents Hydromorphone 1 mg every four hours as needed for moderate pain, pain level 4-7.
Review of the Mediation Administration Records and Assessment and Reassessments documentation indicates the patient received Hydromorphone 1 mg on 05/08/18 at 10:55 AM and at 5:17 PM. There is no evidence of pain assessments prior to the administrations.



5) Physician's Orders for Patient #6 dated 06/12/18 documents Percocet 15 mg every four hours as needed for pain level 5-10.
Review of the Medication Administration Records and Assessment and Reassessments documentation indicates the patient received Percocet 15 mg on 06/12/18 at 2:47 AM and at 6:56 AM. There is no evidence of pain assessments prior to the administrations.



6) Physician's Orders for Patient #10 dated 04/06/18 documents Hydromorphone 0.5 mg every two hours as needed for pain.
Review of the Medication Administration Records and Assessment and Reassessments documentation indicates the patient received Hydromorphone on 04/07/18 at 6:27 AM. There is no evidence of pain assessment prior to the administration.



Interview with The Director of Risk Management, who navigated the electronic record, conducted on 06/19/18 starting at 11:45 AM and on 06/20/18, starting at 8:45 AM confirmed the nursing staff did not follow pain medication parameters and did not complete pain assessments as identified above.

Based on policy review, clinical record review and interview the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5) for 1 of 2 sampled patients (Patient #9) as evidenced by failure to reassess patient's condition after completion of blood transfusion as specified per facility policy.


The findings included:

Facility policy titled "Blood and Blood product Transfusions" dated 06/07/18 documents "To provide guidelines for the safe transfusion and administration of blood products. Infusion of blood products varies depending upon the product, and the patient's condition. The usual time of infusion for red blood cells averages two hours..... Monitor the patient during the remainder of the transfusion. No additional vital signs are required until the completion of the transfusion, unless nursing assessments and or judgment indicates. Team members should remain aware that blood has been transfused and that reaction can present after the transfusion is completed. Documentation of the transfusion and vital signs related to the transfusion should be documented in the computer/medical record and the amount of fluid received included in the patients intake and output.
This procedure must be followed exactly as written."


Clinical record review conducted on 06/20/18 revealed Patient #9 was prescribed a blood transfusion, one unit of red blood cells on 06/08/18 due to low hemoglobin.

The record indicates the blood transfusion was initiated on 06/08/18 at 2:56 PM.

Review of the Nurses Notes, Nursing Shift Assessments and Assessment and Reassessment documentation failed to provide evidence the patient was reassessed after the completion of the blood transfusion.

Interview with The Director of Risk Management on 06/20/18 at 10:22 AM and with The Orthopedic Nurse Manager on 06/20/18 at approximately 11:12 AM confirmed there is no evidence the nursing staff completed a post transfusion assessment.