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Based on record review and staff interview, it was determined that there was inconsistent documentation of the Nursing Assessment for a patient on a "Patient Controlled Analgesia" (PCA) intravenous medication. Specifically, the records failed to document the patient reassessments as required by facility Policy in one (1) out of four (4) records reviewed (Patient #8).

Findings:

Review of the Medical Record for Patient #8 revealed that the patient was admitted on 11/15/14 with a history of Hypertension, Asthma, Dyslipidemia, Peripheral Neuropathy, Peripheral Vascular Disease and Colon Cancer. The patient presented to facility with complaints of left foot pain and was found to have multiple thrombi. The patient developed gastric bleeding and underwent a Hemicolectomy for recurrent Colon Cancer.

Review of the Physician's Orders revealed that the patient was started on an Intravenous Morphine PCA (Patient Controlled Analgesia) pump on 11/14/14 at 3:47PM. The Nurse then documented on the electronic "Order / Task Summary" that the medication was started at 6:00PM. The Controlled Substance Disposition Sheet documents the 100cc infusion was given.

There is no evidence that the Nursing Staff documented reassessments of the patient after the medication was started or every four (4) hours as required by facility Policy and there was no "PCA Administration Flow Sheet" contained in the Medical Record.

The Physician's Orders then revealed that the patient was restarted on a PCA pump on 11/26/14 at 11:16AM, which the Nurse documented was implemented at 2:00PM. The Controlled Substance Disposition Sheet documents 30cc were infused and 70cc were wasted. There is no documentation of reassessment by the Nursing Staff as required.

An interview during the afternoon on 12/16/14 with the Quality Management Coordinator confirmed that the Flow Sheet could not be located and the record did not contain reassessments of the patient on a PCA pump.

Review of the facility Policy titled "Intravenous Patient Controlled Analgesia" dated 11/14 revealed that the patient's Vital Signs (Respiratory Rate, Pulse Oxygen Saturation, Blood Pressure), Pain Score and Level of Sedation are to be monitored immediately, then at five (5) minutes, then at a minimum of every four (4) hours until four (4) hours after the IV-PCA is discontinued.
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