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Based on policy review, medical record review and staff interview the hospital's nursing staff failed to supervise and evaluate patient care by failing to assess pain per policy for 5 of 8 sampled patients (#4, #10, #2, #5, and #6).

The findings include:

Review of current hospital policy entitled "Pain Management" dated 07/2009 revealed, "The presence of pain will be assessed following the 'Assessment/Reassessment of patients, nursing documentation of' Policy....Once medicated, the effectiveness of the dose will be reassessed and documented within one hour...."

Review of current hospital policy entitled "Assessment/Reassessment of Patients, Nursing Documentation of" dated 10/2009 revealed, "Assessment of patients occurs at admission, with any change in patient condition, and/or change in patient care assignment and at a minimum - every shift...."

1. Closed medical record review for Patient #4 revealed a 50 year-old male that was admitted to the inpatient rehabilitation unit on 09/30/2009 with severe debility due to post intraventricular hemorrhage (bleeding in the brain). Record review revealed the patient was discharged to home on 10/14/2009. Record review revealed the patient intermittently complained of pain at the incision on his head throughout the hospitalization. Record review revealed no documentation nursing staff assessed the patient's pain on 10/03/2009 and 10/04/2009 during the 0700-1900 shift. Further record review revealed the patient was given Percocet (narcotic pain medication) 2 tablets by mouth for complaints of pain at the following times with pain reassessment as noted:
? on 10/02/2009 at 0500 - next documentation of pain assessment at 1241 (7 hours and 41 minutes after the administration of pain medication);
? on 10/03/2009 at 0615 - next documentation of pain assessment at 1900 (12 hours and 24 minutes after the administration of pain medication);
? on 10/05/2009 at 0720 - next documentation of pain assessment at 0930 (2 hours and 10 minutes after the administration of pain medication);
? on 10/06/2009 at 1200 - next documentation of pain assessment at 1447 (2 hours and 47 minutes after the administration of pain medication);
? on 10/06/2009 at 1810 - next documentation of pain assessment at 2336 (5 hours and 26 minutes after the administration of pain medication) and
? on 10/06/2009 at 2345 - next documentation of pain assessment on 10/07/2009 at 0900 (9 hours and 15 minutes after the administration of pain medication).

Interview on 03/11/2010 at 1530 with the Nurse Manager of the inpatient rehabilitation unit revealed nursing staff should assess all patients for pain at least once per shift. Interview revealed nursing staff should assess pain within one hour of the administration of pain medications.

Interview on 03/11/2010 at 1350 with administrative nursing staff confirmed there was no available documentation the nursing staff assessed the patient's pain on 10/03/2009 and 10/04/2009 during the 0700-1900 shift. Further interview confirmed there was no available documentation the nursing staff reassessed the patient's pain within one hour of the administration of pain medications on 10/02/2009 at 0500; on 10/03/2009 at 0615; on 10/05/2009 at 0720 and on 10/06/2009 at 1200, 1810 and 2345.

2. Open medical record review on 03/11/2010 for Patient #10 revealed a 67 year-old female that was admitted to the inpatient rehabilitation unit on 03/05/2010 for rehabilitation following bilateral knee replacement surgery. Record review revealed the patient was given Percocet (narcotic pain medication) 2 tablets by mouth for complaints of pain on 03/08/2010 at 2133. Record review revealed the first available documentation of pain reassessment was at 2300 (1 hour and 27 minutes after pain medication).

Interview on 03/11/2010 at 1530 with the Nurse Manager of the inpatient rehabilitation unit revealed nursing staff should assess pain within one hour of the administration of pain medications. Interview confirmed there was no available documentation the patient's pain was reassessed within one hour of the administration of pain medication on 03/08/2010 at 2133.

3. Closed medical record review for Patient #2 revealed a 66 year-old female that was admitted on 02/23/2010 for a left total hip arthroplasty (surgical hip replacement). Record review revealed the patient was discharged on 02/26/2010. Record review revealed the patient was given Percocet (narcotic pain medication) 1 tablet by mouth for complaints of pain at the following times with pain reassessment as noted:
? on 02/24/2010 at 0748 - next documentation of pain assessment at 1209 (4 hours and 21 minutes after the administration of pain medication);
? on 02/24/2010 at 2150 - next documentation of pain assessment at 2309 (1 hour and 19 minutes after the administration of pain medication) and
? on 02/25/2010 at 1647 - next documentation of pain assessment at 1825 (1 hour and 38 minutes after the administration of pain medication).
Further record review revealed the patient was given Percocet 2 tablets by mouth for complaints of pain on 02/26/2010 at 0843. Record review revealed the next available reassessment of the patient's pain was at 1117 (2 hours and 34 minutes after the administration of pain medication).

Interview on 03/11/2010 at 1350 with administrative nursing staff revealed nursing staff should reassess pain within one hour of the administration of pain medications. Interview confirmed there was no available documentation the nursing staff reassessed the patient's pain within one hour of the administration of pain medications on 02/24/2010 at 0748 and 2150; on 02/25/2010 at 1647 and on 02/26/2010 at 0843.

4. Closed medical record review for Patient #5 revealed a 70 year-old male that was admitted to the inpatient rehabilitation unit on 02/23/2010 for rehabilitation following bilateral knee replacement surgery. Record review revealed the patient was discharged on 02/27/2010. Record review revealed the patient was given Percocet (narcotic pain medication) 2 tablets by mouth for complaints of pain at the following times with pain reassessment as noted:
? on 02/23/2010 at 1555 - next documentation of pain assessment at 1900 (3 hours and 5 minutes after the administration of pain medication);
? on 02/24/2010 at 1105 - next documentation of pain assessment at 1541 (4 hours and 36 minutes after the administration of pain medication) and
? on 02/27/2010 at 0533 - next documentation of pain assessment at 0719 (1 hour and 16 minutes after the administration of pain medication).

Interview on 03/11/2010 at 1530 with the Nurse Manager of the inpatient rehabilitation unit revealed nursing staff should assess pain within one hour of the administration of pain medications.

Interview on 03/11/2010 at 1350 with administrative nursing staff confirmed there was no available documentation the nursing staff reassessed the patient's pain within one hour of the administration of pain medications on 02/23/2010 at 1555; on 02/2/2010 at 1105 and on 02/27/2010 at 0533.

5. Closed medical record review for Patient #6 revealed a 29 year-old female that was admitted on 02/17/2010 with pancreatitis. Record review revealed the patient was discharged on 02/19/2010. Record review revealed the patient was given Dilaudid (narcotic pain medication) 4 milligrams intravenously for complaints of pain at the following times with pain reassessment as noted:
? on 02/18/2010 at 0111 - next documentation of pain assessment at 0340 (2 hours and 29 minutes after the administration of pain medication);
? on 02/18/2010 at 0549 - next documentation of pain assessment at 0750 (2 hours and 1 minute after the administration of pain medication) and
? on 02/19/2010 at 0644 - next documentation of pain assessment at 1030 (3 hours and 46 minutes after the administration of pain medication).

Interview on 03/11/2010 at 1350 with administrative nursing staff revealed nursing staff should reassess pain within one hour of the administration of pain medications. Interview confirmed there was no available documentation the nursing staff reassessed the patient's pain within one hour of the administration of pain medications on 02/18/2010 at 0111 and 0549 and on 02/19/2010 at 0644.

Based on policy review, closed medical record review and staff interview the hospital's nursing staff failed to assess vital signs during a blood transfusion for 3 of 4 sampled patients that received blood transfusions (#1, #2 and #3).

The findings include:

Review of current hospital policy entitled "Blood and Blood Products Transfusion" dated 01/2010 revealed, "PURPOSE: To provide guidelines for the safe administration of blood/blood products....NURSING ACTION....7. Take vital signs and record....To obtain a baseline of data prior to transfusion....19. Document observation of patient for first 15 minutes. Check vital signs and record in the patient record....20. Observe the patient closely and check vital signs at least hourly until one (1) hour after transfusion or per physician's order....To compare vital signs to baseline. Acute reactions may occur at any time during the transfusion....25. IN CASE OF SUSPECTED TRANSFUSION REACTION:....Treat symptoms per physician order and monitor vital signs...."

1. Medical record review of Patient #1 revealed a 77 year-old female that was admitted on 02/11/2010 for a hiatal hernia (part of the stomach protrudes up through the diaphragm into the chest) and atrial fibrillation (irregular heart rhythm). Record review revealed the patient was treated and subsequently discharged on 02/20/2010. Record review revealed on 02/15/2010 the patient received a transfusion of Fresh Frozen Plasma (a blood product). Record review revealed the transfusion was started at 1707 and was stopped at 1752, when the patient developed redness and whelps on her torso, neck and arms (signs of possible transfusion reaction). Record review revealed documentation of vital signs at 1637, 1719 and 1753. Record review revealed the next documentation of vital signs was at 2124 (3 hours and 32 minutes after the transfusion was stopped due to signs of a possible transfusion reaction).

Interview on 03/11/2010 at 1200 with the registered nurse that administered the blood transfusion to Patient #1 on 02/15/2010 revealed vital signs should be assessed prior to and 15 minutes after the start of a transfusion, every hour during a transfusion and one hour after the stop of a transfusion. Interview revealed the nurse stopped Patient #1's blood transfusion at 1752 because she was concerned the patient might have had a transfusion reaction, due to the hives on her arms, neck and torso. Interview revealed the nurse notified the physician of the reaction and reported it to the blood bank. Interview revealed the nurse's usual practice was to document vital signs in the medical record when they were assessed. Interview confirmed there was no available documentation the patient's vital signs were assessed one hour after the transfusion was stopped due to a possible transfusion reaction.

Interview with administrative nursing staff on 03/11/2010 at 1350 vital signs should be assessed prior to and 15 minutes after the start of a transfusion, every hour during a transfusion and one hour after the stop of a transfusion. Interview confirmed the first available documentation the patient's vital signs were assessed after the transfusion ended on 02/15/2010 at 1752 was at 2124 (3 hours and 32 minutes after the transfusion was stopped due to signs of a possible transfusion reaction).

2. Medical record review of Patient #2 revealed a 66 year-old female that was admitted on 02/23/2010 for a left total hip arthroplasty (surgical hip replacement). Record review revealed the patient was treated and subsequently discharged on 02/26/2010. Record review revealed on 02/24/2010 the patient received a transfusion of Packed Red Blood Cells (a blood product). Record review revealed the transfusion was started at 1200 and was completed at 1425. Record review revealed documentation of vital signs at 1153, 1223, 1317 and 1417. Record review revealed the next documentation of vital signs was at 1956 (5 hours and 31 minutes after the transfusion was completed).

Telephone interview on 03/11/2010 at 1320 with the nurse that administered the blood transfusion to Patient #2 on 02/24/2010 revealed the nurse was not aware the of the hospital's policy to assess vital signs one hour after the completion of a blood transfusion.

Interview with administrative nursing staff on 03/11/2010 at 1350 vital signs should be assessed prior to and 15 minutes after the start of a transfusion, every hour during a transfusion and one hour after the stop of a transfusion. Interview confirmed the first available documentation the patient's vital signs were assessed after the transfusion ended on 02/24/2010 at 1425 was at 1956 (5 hours and 31 minutes after the transfusion was completed).




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3. Medical record review of Patient #3 revealed a 72 year-old male who was admitted on 9/29/2009 with a right temporal epidural hematoma (a collection of blood formed around the brain). Record review revealed the patient had back surgery 2 weeks prior to admission. Record review revealed the patient was treated and subsequently discharged on 10/15/2009. Record review revealed on 9/29/2009 the patient received a transfusion of Fresh Frozen Plasma (a blood product). Record review revealed the transfusion was started at 2314 and was completed on 09/30/2009 at 0118. Record review revealed documentation of vital signs at 2310, 2330 and 0030. Record review revealed the next documentation of vital signs was at 0400 (2 hours and 42 minutes after the transfusion was completed).

Interview with administrative nursing staff on 3/11/2010 at 1415 confirmed there was no available documentation that the nurse assessed the patient's vital signs one hour after the completion of the blood transfusion per policy.


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