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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 1 of 3 sampled patients (Patient #1) as evidenced by failure to assess pain as specified in the facility policies and procedures and failure to implement pain management orders to manage the patient's complaints of pain.


The findings included:


Facility policy titled "Pain Management", effective 01/15/19, documents "The purpose of this policy is to provide guidelines for the clinical staff to fully assess, reassess and manage the pain of the patient.
Pain scale will be used to evaluate the patient. Initiate plan of care for any patient who identifies pain. Encourage the use of non- pharmacological pain treatment modalities.
Medication administration: For moderate pain (4-7), consider Opioid in conjunction with non-Opioid. Severe pain (7-10) Opioid alone or in conjunction with adjuvant.
If pain uncontrolled on two successive re-assessment/interventions, re-evaluate the pain and determine different interventions. Reevaluate non-pharmacological interventions as well."


Clinical record review conducted on 10/14/19 revealed Patient #1 was admitted to the facility on 03/04/19 with complaints of chest pain.

Physician's orders dated 03/05/19 at 12:07 AM documents Dilaudid 2 mg intravenously every four hours as needed for pain.
Physician's order dated 03/05/19 at 12:47 PM documents Dilaudid 2 mg intravenously every two hours as needed.
Physician's order dated 03/04/19 documents Tylenol 650 mg every four hours as needed for pain on scale 1-3.

Nurses Notes dated 03/05/19 at 11:38 AM revealed Patient #1 continues to complain of chest pain, pain seven out of ten.

The record indicates the patient was last medicated for pain on 03/05/19 at 7:28 AM (four hours prior to the nursing entry).

The record failed to provide evidence the clinical staff addressed the complaints of pain by medicating the patient with the prescribed Dilaudid. The record does not provide evidence of patient's refusal of pain medication or rationale for not administering the prescribed Dilaudid as needed. The record validates Patient #1 was in pain from 11:38 AM thru 1:11 PM.
The record also failed to provide evidence of non pharmacological interventions implemented to aid the patient in managing the pain.

Subsequent entries in the record indicates Patient #1 received Dilaudid three hours after reporting pain at scale seven out of ten at 1:11 PM. Nurses Notes document at 2:30 PM the pain escalated to nine out of ten despite intervention and remained at level five as of 3:39 PM. No further interventions were documented.

Nurses Notes dated 03/05/19 at 6:40 PM documents patient with increased restlessness and requesting sedation, subsequently became unresponsive and rapid response was called.

Interview with The Director of Quality and The Quality Coordinator conducted on 10/15/19 at approximately 10:12 AM confirmed the record does not provide rationale for not administering pain medication as ordered.

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) for 1 of 1 sampled patient (Patient #5). This failure is evident by failure to assess and reassess patient's condition during blood transfusions as specified in facility policy for Blood Product Administration.


The findings included:

Facility policy titled "Blood Product Administration" dated 07/30/18 documents "To define the requirements and staff roles when administering blood products.
Procedure:
Begin the transfusion as soon as possible after baseline vitals signs are obtained.
Remain at patient bedside for first 15 minutes to monitor signs of a transfusion reaction.
Obtain vital signs 15 minutes after the blood transfusion begins to enter the vein and at least hourly throughout the transfusion.
Obtain post transfusion vital signs within 30 of completion.


Clinical record review conducted on 10/14/19 revealed Patient #5 was prescribed a blood transfusion, one unit of red blood cells on 10/02/19 due to low hemoglobin.

The record indicates the blood transfusion was initiated on 10/02/19 at 4:30 PM.

Review of the Nurses Notes, Nursing Shift Assessments and Reassessment and vital signs documentation and blood administration record failed to provide evidence the patient was monitored an hour after the transfusion was initiated as specified in the facility policy.

Interview with The Director of Patient Safety and The Quality Coordinator, who navigated the electronic documentation, on 10/14/19 at approximately 3:16 PM confirmed there is no evidence the nursing staff monitored Patient #5's vital signs as specified by the facility policies and procedures.