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LINDSAY MUNICIPAL HOSPITAL
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on record review and interview, the hospital failed to ensure reassessment of pain medication administration for one (Patient #1) of ten patients.
This failed practice has the likelihood to result in no assessment of a patient's clinical condition and delayed intervention.
Review of a facility policy titled "Pain Assessment and Reassessment Tools" read in part, "Document information about the pain and response to intervention."
Patient #1
Review of the electronic medication record (EMR) showed acetaminophen-hydrocodone was administered for pain on 4/11/22 at 8:55 AM and pain reassessment not completed per facility policy.
On 04/14/20, Staff D reviewed the EMR for Patient #1 and stated the pain reassessment was not completed per facility policy.
CONTENT OF RECORD: HISTORY & PHYSICAL
Tag No.: A0458
Based on record review and interview, the hospital failed to ensure the practitioner completed the History and Physical (H&P) for five (Patient #1, 2, 4, 6, and #9) of 10 patients.
This failed practice has the likelihood to place patients at risk of receiving care that is non-therapeutic and not having their individualized patient history information communicated.
A facility document titled "Medical Records Completion" stated "History and physical examinations shall be completed, signed, and placed in the medical record within 24 hours following the admission."
Findings:
Patient #1
Review of patient electronic medical record (EMR) "History and Physical" showed Patient #1 was admitted on 03/18/22 and the practitioner signed the document on 03/21/22.
On 04/14/22, Staff D stated that this H&P was not signed within the appropriate time frame.
Patient #2
Review of patient electronic medical record (EMR) "History and Physical" showed Patient #2 was admitted on 02/15/22 and the practitioner signed the document on 02/19/22.
On 04/14/22, Staff D stated that this H&P was not signed within the appropriate time frame.
Patient #4
Review of patient electronic medical record (EMR) "History and Physical" showed Patient #4 was admitted on 04/08/22 and the practitioner signed the document on 04/11/22.
On 04/14/22, Staff D stated that this H&P was not signed within the appropriate time frame.
Patient #6
Review of patient electronic medical record (EMR) "History and Physical" showed Patient #6 was admitted on 04/06/22 and the practitioner signed the document on 04/08/22.
On 04/14/22, Staff D stated that this H&P was not signed within the appropriate time frame.
Patient #9
Review of patient electronic medical record (EMR) "History and Physical" showed Patient #9 was admitted on 04/11/22 and did not receive an H&P.
On 04/14/22, Staff D stated patient #9 did not have an H&P in the patient's chart.