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Based on document review and staff interview, it was determined the facility failed to develop a policy and procedure for assessing patients prior to and following the administration of pain medications, and failed to ensure post nursing assessments were performed following the administration of pain medication (Patient #2).

Findings include:

Facility policy Medications in the Nursing Departments included: "Policy: To establish criteria to store medications in the Nursing departments. Responsibilities/Procedures: All medications will be stocked per par levels established between the Nursing Departments and the Pharmacy.: 1. Automated dispensing machines will be stocked by Pharmacy when par levels are low: Staff shall be assigned access codes to the automated dispensing machines. Narcotics locked in automated dispensing machines will be counted per Pharmacy protocol...."

No policy was found that included the administration of pain medication by the nursing staff. No policy or procedure requiring the nurse to document pre and post pain assessments was provided upon request.

The Emergency Department Manager verified during an interview conducted on 08/09/12, the pre and post assessments for the administration of pain medications was not found in a pharmacy or nursing policy.

Patient #2 was given Morphine Sulfate (MS) 15 mg CR every 12 hours with the first dose being given at 1430 on 10/24/12; Percocet 1 tablet was given every 6 hours for breakthrough pain. Nursing notes reveal the patient' pain was relieved when receiving these medications. No documentation was found why the night RN on 10/25/09, administered MS 2 mg IVP and Ativan 2 mg IVP to the patient at 0502. The night RN's last documentation in the nurses notes was at 04:44. The day shift RN received a call from the patient's wife that the patient wasn't responsive at 0815. The RN found the patient lethargic with an oxygen saturation of 83%. The RN failed to assess and monitor the patient after administering pain medications.

The Emergency Department Manager verified in an interview conducted on 08/09/12, no documentation could be found the patient was assessed prior to receiving the MS and Ativan at 0502 hours. She acknowledged no documentation was found the patient was re-assessed and monitored after the medication was given from 0502 hours until 0815 hours.

Based on observation, document review, and staff interviews, it was determined the facility failed to ensure patient safety for 2 of 3 patient's reviewed (Patient's #1 and 2).

Findings include:

Patient #1

The facility fall prevention policy included: "Upon admission to NCCH and upon any change in level of status, or in the event of a fall or un-witnessed fall, all patients admitted to Northern Cochise Community Hospital will be screened for potential fall and safety risks using the Fall Risk Screening Form. All patients admitted whose initial screening results in 10 points or more will be re-evaluated weekly and PRN for changes in clinical condition utilizing a repeat Fall Risk Assessment and appropriate interventions. Responsibilities: Nursing-It is the admitting nurse's responsibility to initiate a fall risk screening and interventions on all patients upon admission to the hospital or upon any change in the patient's status...Procedure: 3. The nurse caring for the patient will initiate the Fall Risk Assessment and Interventions upon change in level of care, in the event of a fall or un-witnessed fall or a change in condition of the patient."

Patient #1 was admitted to the hospital on 12/07/11, for hypoglycemia. The admission history and physical revealed the patient was found unresponsive in a group home with a blood sugar of 60. Past medical history included: "1. Gastroesophageal reflux. 2. Chronic urinary tract infection. 3. Hypertension. 4. Dementia. 5. Diabetes."

The admission physician orders included: "Fall Precautions."

The fall risk assessment done on 12/07/11, at 1305 hours by the admitting Registered Nurse (RN) revealed a score of 7. The adult shift assessment, done by an RN every 12 hours, revealed the last question: "Have you reviewed your fall risk interventions?"

Patient #1 was placed on standard fall risk interventions with the additional yellow risk intervention of being in a room closer to the nurses station - Room 105. A tour of the facility conducted on 08/07/12, revealed Room 105 was directly across the hall from the right side of the nurses station.

The nursing progress noted on 12/08/11 at 0925 hours revealed: "Foley discontinued...Patient tolerated procedure well." Patient #1 was incontinent of urine x 5 during the day shift.

RN #13's nursing progress note on 12/08/2011, at 2000 hours, included: "Received report. Assumed care of patient. Pt sitting in bed, pleasant. States she has no needs and will call if she needs help. Call light in reach, though pt has been heard from the station calling for people other than those that are working. Will continue to monitor."

RN #13's nursing note at 2100 hours included: Gave report to (RN #5). Pt refused PM meds from (RN #5) and myself. Pt was oriented only to self. She states that she's not in the hospital and those are not her pills. Her resolve to not take the meds was solid. She states that she has no needs." Pt's PM medications included: "Risperidone (antipsychotic) 1 mg tab at bedtime." No documentation was found that the physician was notified the patient refused her medication.

RN #5's nursing progress note on 12/08/11, at 2330 hours included: "Pt laying in bed with eyes closed. Pt was slow to arouse. Pt eventually awoke and was confused. Pt oriented x 1 to person only. Pt refused physical assessment and kept referring to '(Name)'. Pt refused to take PM medications stating 'they are not my pills'. Will attempt to have another female nurse administer medication. Pt denies needing anything at this time. Bed in lowest and locked position, bedrails up x 2, bedside table and call light within reach. Will continue patient plan of care."

The nursing note by RN #5 at 0029 hours included: "Heard pt talking went into pt. room and found patient on the floor at the foot of her bed. Assessed pt and found 2 skin tears, one on each forearm. Asked pt if she hit her head. Pt states 'yes' and points to the right upper forehead region. Assessed the region and no bleeding, cuts or reddend (sic) areas noted. Inspected entire head area with not (sic) findings. Assisted pt back to bed with the help of another RN. Dressed wounds with steri strips, oil gauze and wrapped with kerlex. Pt placed on tab alarm attached to gown. MD notified and CT of head without contrast ordered. Bed in lowest position and locked position, bedrails up x 2, bedside table and call light within reach. Will continue patient plan of care."

RN #5 nursing note at 0200 hours included: "Pt laying in bed with eyes closed. Equal and unlabored breathing noted bilaterally. Pt does not display any outwards signs of pain or distress at this time. Call light within reach, tab alarm attached to gown. Will continue plan of care."

RN #5's nursing note at 0348 hours revealed the same exact documentation as previously written at 0200 hours.

RN #5's nursing note at 0436 hours included: "check up on patient and pt is looking around. Pt complains of pain to her left hip are (sic). Upon assessing there is no reddness (sic) or any irritation noted on the skin. The pt denies pain when you press on outside hip and leg area. pt denies pain with movement of leg up and down and side to side motion. Pt states, she want to go to bed now and need (sic) help into bed. Pt is informed that she is already in bed and that it is ok to got (sic) to bed. Pt asked if she thinks she will be able to sleep. Pt states yes. Tab alarm in place, call light within reach, tab alarm attached to gown. Will continue plan of care."

RN #5's nursing note at 0601 hours included: "...pt in no pain or distress...tab alarm attached to gown...."

RN #4's nursing note at 0915 hours included: Report received by night shift RN. Adult shift assessment completed at this time. Patient complaints of severe pain to the left lower extremity with any type of manipulation. Patient left Lower extremity is shorter then the right and with lateral rotation present. Dr.____ notified immediately (sic) and STAT x-ray of hips bilaterally ordered. Dr. _____ in to see patient. IV (intravenous) is at continuous 75 ml (millimeter)/hr...."

Patient #1's x-ray of the left hip results included: "Subcapital fracture left femoral neck with superolateral displacement of the shaft with respect to the femoral head."

Patient #1 was transferred to an acute hospital on 12/09/11, at 1510 hours, for orthopedic care.

The Emergency Department Manager verified the patient should have received further fall risk assessments with the implementation of the tab alarm prior to her fall.

Patient #2

Patient #2 was admitted for observation to the Med/Surg Unit on 10/24/2009, at 1330 hours, for proximal left thigh pain/numbness.

The admission History and Physical (H&P) revealed: "diagnostic data:...Ct scan of the L-spine with and without contrast basically showed mild anterior wedge-compression deformity of T (thoracic) 12 and L(lumbar)1, likely chronic advanced disc space height loss and endplate degenerative changes from L3 to L4 through L5 to S (sacral) 1, and minimal retrolisthesis of L3 on L4. The most important finding was the large disc extrusion at L2-L3, which extended inferiorly along the superior aspect of the L3 vertebral body along the left side of the central canal, obliterates the left lateral recess likely impinging numerous left-sided nerve roots including the left L3 and L4 nerve roots...Assessment and Plan: 1. Left thigh pain. At this point, we will start the patient on gabapentin (Neurontin) given the fact this is a neuropathic pain, also we will start the patient on long-acting morphine and short-acting morphine to control pain...."

The Medication Administration/Physician Order records revealed that Patient #2 received his first dose of Morphine Sulfate (MS Contin) CR (continuous release) 15 milligrams (mg) at 1403 hours on 10/24/09, and the second dose at 0041 hours on 10/25/09. He received Percocet 5/325 1 tablet at 1845 on 10/24/09 and the second dose at 004 hours on 10/25/09. Patient #2 received Ativan (Lorazepam) 2.0 mg IVP (intravenous push) at 0502 hours on 10/25/09, along with Morphine Sulfate 2.0 mg IVP.

RN #6 nursing progress notes for 10/25/09, included: "02:00 - Patient with no complaints. Bed in low position. Call light within reach. Verbalized no needs at this time." 04:44 - O2 system, including bubble humidifier, checked and working well. No further nursing progress notes were found for Patient #2 on the night shift.

Nursing progress notes by RN #4 on 10/25/09, at 0815 hours, included: "Received a frantic phone call from the patients wife, stating that she was speaking with him when he become (sic) unresponsive to their conversation. Upon entering the room the patient was found very lethargic, nasal cannula was found lying in the bed. Vital signs obtained, BP (blood Pressure) 97/52, HR (heart rate) 86, o2 sat's (saturation) 82%. Nasal cannula placed back on patient, oxygen set at 6 L/Min. (liters/Minute). Lung sounds obtained, rhonchi auscultated throughout all fields, patient does have a productive cough. Oxygen sat's 83% on 6 L of o2, patient placed on non-rebreather mask by _____, RT (respiratory therapy), oxygen set to 15 L, sats 85%, patient placed upright in 45 degree angle. Appears very sleepy, does answer questions when spoke to."

The nursing notes revealed: 1. 0825 hours. The patient was put on BiPAP 12/8 at 100% oxygen to assist with his breathing. 2. The physician arrived to the bedside at 0855 hours. 3. Romazicon 0.2 mg IVP was given at 0855 hours, 0900 hours, 0910 hours and 0920 hours to reverse the effects of Ativan.

The Respiratory Therapist (RT) initial BIPAP assessment pf 10/25/09, at 0815 a.m., included: "major complaint - hypoxia with shortness of breath." 1525 hours; "Pt unable to tolerate BiPAP, c/o (complains/of)-to-emisis (sic). Dr.____ causes more emisis (sic) by deep suctioning LT (left) nare." RT notes verified by the Case Manager on 08/08/12.

The physician acknowledged during an interview conducted on 08/07/12, at 0130 p.m., he wasn't sure when Patient #2 aspirated. The patient was put on BiPAP, Romazicon was given, and the patient consented to be intubated and transferred to an acute care hospital at 2250 hours on 10/25/09.

The Emergency Department Manager verified in an interview conducted on 08/09/12, no documentation could be found the patient was assessed prior to receiving the MS and Ativan at 0502 hours. She acknowledged no documentation was found the patient was re-assessed and monitored after the medication was given from 0502 hours until 0815 hours.

Based on document review, and staff interview, it was determined the facility failed to monitor patient safety by tracking and trending falls, transfers of patients, and adverse events.

Findings include:

The facility policy and procedure on event reporting included: "Policy: All unanticipated events involving patients, visitors, students, non-employee or employees of Northern Cochise Community Hospital shall be documented, reported and reviewed for further investigation. An unanticipated event is any situation that is not consistent with the routine operation of the hospital or routine care of patients. Purpose: Ensure the timely completion of the event report for review, necessary interventions and QI purposes."

The Emergency Department (ED) Manager acknowledged in an interview conducted on 08/09/12, adverse events can be entered into the Electronic Medical Record system by any staff member and are reviewed by the Chief Nursing Officer; Quality and Risk Manager.

Review of the Quality Improvement Committee (QI) minutes for the past 3 months revealed no documentation of tracking and trending for falls, transfers, or adverse events.

An interview conducted with the Chief of Staff on 08/09/12 at 0750, revealed the facility did not have any falls in June and only 1 fall in July.

The Emergency Department Manager verified the facility didn't have any falls in June and only 1 in July; but no documentation for the tracking of falls since 12/2011, was provided upon request.

The CEO acknowledged the facility reviews the first transfer of each month but not all transfers.

The ED Manager acknowledged the facility was not currently tracking and trending falls, transfers, and adverse events in QI.