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Tag No.: A0385
Based on the seriousness of the non-compliance and the potential effect on patient outcome, the facility failed to substantially comply with this condition.
The findings were:
482.23 Tag A-0385
The information reviewed during the survey provided evidence the facility failed to ensure nursing staff on the medical/surgical unit were provided adequate supervision regarding following approved facility policies.
A discussion took place with the survey team and the facility's administrative staff (EMP1, EMP2, and EMP6) regarding the survey team's concerns related to Patient's Rights on August 22, 2022, at 1045.
Continuing deficiency cited August 23, 2022.
Cross reference
482.23 (b)(6) Nursing Services: Supervision of Contract Staff
Tag No.: A0398
Based on review of facility policy and medical records (MR) and staff (EMP) interview, it was determined the facility failed to ensue pain medications were administered as ordered for two of eight MRs reviewed (MR3 and MR4); failed to ensure pain reassessment was documented for two of eight MRs reviewed (MR3 and MR5), and; failed to ensure documentation of provider receipt of a critical value in three of eight MRs reviewed (MR7, MR8 and MR10), and; failed to ensure physician orders were initiated promptly for three of three MRs reviewed (MR5, MR6, and MR7).
Findings include:
Review on November 3, 2022, of facility policy, "Physician Medication Orders Including Advanced Practice Professionals," last revised September 2022, revealed "Purpose: To ensure that orders are accurately received, written, transcribed, verified and implemented for the correct patient. ... Responsible Persons...Medication Ordering Guidelines...H. All medication orders will include the name of the medication, dose, route, specific frequency. PRN indication and specific area for topical application. 1. All PRN medications must be qualified as to the prescriber's intent. PRN medications cannot have the same indication for use. The order must be clarified so each order is differentiated from the other. (For example: pain must be clarified to mild pain (pain scale 1-3), moderate pain (pain scale 4-6), or severe (pain scale 7-10). ..."
Review on November 3, 2022, of facility policy "Pain Management Policy," dated September 6, 2022, revealed "...II. Purpose The purpose of this policy is to provide direction to health care providers regarding the assessment and management of pain...VI. Reassessment Reassessment for the presence of pain following pain-relieving interventions is essential for effective pain management. Reassessment will include intensity, using an appropriate pain scale or a description of behaviors and physiological response, level of sedation (per age-appropriate sedation scale), and outcome. ..."
Review on November 4, 2022, of MR3 revealed an order for Acetaminophen 500 mg every six hours as prn (as needed) for mild pain of 1-3. Review revealed the medication was administered to MR3 on October 27, 2022, at 0326 for a pain scale of 7, at 1024 for a pain scale of 5, at 1625 for a pain scale of 7 and at 2224 for a pain scale of 8. There was no documentation in MR3 of a patient preference for a less potent pain medication for moderate or severe pain. Further review of MR3 revealed there was no documentation of pain reassessment following the administration of Acetaminophen at 1325 on October 27, 2022.
Interview with EMP4 on November 3, 2022, at 1100 confirmed there was no documentation in MR3 of patient preference for a less potent pain medication for the administration of Acetaminophen at 0326, 1024, 1625, and 2224 on October 27, 2002. EMP4 confirmed there was no documentation of pain reassessment following the administration of Acetaminophen at 1325 on October 27, 2022.
Review on November 3, 2022, of MR4 revealed an order for Oxycodone/Acetaminophen 325mg/5mg one tablet every six hours prn for moderate pain (4-6). Review revealed MR4 was administered Oxycodone/Acetaminophen 325mg/5mg on October 17, 2022, for a pain scale of 10. There was no documentation in MR4 of a patient preference for a less potent pain medication for moderate or severe pain.
Interview with EMP4 on November 3, 2022, at 1115 confirmed there was no documentation in MR4 of patient preference for a less potent pain medication for the administration of the Oxycodone/Acetaminophen.
Review on November 4, 2022, of MR5 revealed an order for Acetaminophen 650 mg for mild pain 1-3. MR5 received the Acetaminophen at 1235 on November 2, 2002, for a pain scale of 8. There was no documentation of patient preference for a less potent pain medication for severe pain. Further review revealed MR5 received morphine sulfate IV for chest pain at 0922. There was no documentation of pain reassessment following the administration of the morphine sulfate.
Interview with EMP5 on November 4, 2022, at 1340 confirmed there was no documentation in MR5 of patient preference for a less potent pain medication for the administration of Acetaminophen at 1235 on November 2, 2002. EMP4 confirmed there was no documentation of pain reassessment following the administration of the morphine sulfate at 0922 on November 2, 2022.
Review on August 22, 2022, of facility policy "Critical Values Results Reporting," approved March 2022, revealed "...1. RN/RT Documentation for critical laboratory or· point of care testing (POCT): ...1. The RN will document the receipt of the critical value and the notification of the provider in the Critical Results Notification Form. ..."
Review on November 4, 2022, of MR7 revealed a nurse attempted to notify the provider of a critical lab result at 0325 on November 4, 2022. There was no documentation the provider returned the call and received the result.
Interview with EMP5 on November 4, 2002, at 1415 confirmed there was no documentation in MR7 the physician responded to the notification of a critical lab result.
Review on November 4, 2022, of MR8 revealed a nurse received notification of a critical lab result for a low white blood cell count at 1956 on November 3, 2022. Documentation of notification to the provider was not completed. Further review revealed a nurse received notice of a critical lab result for a low white blood cell count at 0824 on November 4, 2022. Documentation of notification to the provider was not completed.
Interview with EMP5 on November 4, 2002, at 1415 confirmed there was no documentation of physician notification of critical lab results at 1956 on November 3 and at 0824 on November 4, 2022.
Review on November 4, 2022, of MR10 revealed a nurse received notification of a critical lab result for an elevated lactate on November 4, 2022, at 0011. There was no documentation of the name of the physician notified of the result.
Interview with EMP5 on November 4, 2002, at 1415 confirmed there was no documentation of the name of the physician notified of the critical lab result received at 0011 on November 4, 2022.
Interview with EMP5 on November 4, 2022, at approximately 1340, revealed the facility's accepted standard of practice was to ensure orders for continuous cardiac monitoring (telemetry) were initiated within one hour.
Review of MR5 on November 4, 2022, revealed MR5 was on telemetry in the emergency department (ED). Admission and telemetry orders were place at 1332 on November 2, 2022. MR5 was transferred to the medical/surgical unit as an inpatient on November 2, 2022, at 1550. There was no documentation of telemetry in place on the medical surgical unit until 2030 on November 2, 2022.
Interview with EMP5 on November 4, 2022, at 1345 confirmed there was no documentation in MR5 of telemetry in place within an hour of admission to the inpatient unit at 1550 on November 2, 2022.
Review of MR6 on November 4, 2022, revealed MR5 was in the ED on November 3, 2022. Admission and telemetry orders were place at 1349 on November 3, 2022. MR6 was transferred to the medical/surgical unit as an inpatient on November 3, 2022, at 1404. There was no documentation of telemetry in place on the medical surgical unit within an hour of admission to the inpatient unit.
Interview with EMP5 on November 4, 2022, at 1345 confirmed there was no documentation in MR6 of telemetry in place within an hour of admission to the inpatient unit at 1404 on November 3, 2022.
Review of MR7 on November 4, 2022, revealed MR7 was on telemetry in the ED on November 3, 2022. Admission and telemetry orders were place at 1857 on November 3, 2022. MR5 was transferred to the medical/surgical unit as an inpatient on November 3, 2022, at 1825. There was no documentation of telemetry in place on the medical surgical unit until 2022 on November 3, 2022.
Interview with EMP5 on November 4, 2022, at 1345 confirmed there was no documentation in MR7 of telemetry in place within an hour of admission to the inpatient unit at 1825 on November 3, 2022.
Interview with EMP3 on November 3, 2022, at 1430 confirmed all applicable nursing staff had completed education regarding facility policies "Physician Medication Orders Including Advanced Practice Professionals", and "Pain Management Policy" and "Critical Values Results Reporting" and the accepted time frame of one hour for the initiation of physician orders.