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MEMORIAL HERMANN MEMORIAL CITY MEDICAL CENTER
ADMINISTRATION OF DRUGS
Tag No.: A0405
Based on observation, interview and record review, the facility failed to ensure the reassessment of pharmacologic interventions as outlined per hospital policy.
The facility failed to ensure nursing staff reassessed pain effectiveness in four (4) out of ten (10) patients. (ID #3, 6, 8, 9).
Findings including:
Patient # 3
Record review on 7/26/2018 of the medical administrative record (MAR) for Patient (ID#3) dated 7/24/2018 revealed Morphine 4 mg was given at 1:26 p.m. intravenously for a pain score of seven (7). A pain re-assessment was not completed for effectiveness.
Patient # 6
Record review on 7/26/2018 of the medical administrative record (MAR) dated 7/25/2018 for Patient (ID#6) revealed Morphine 2 mg was given at 2:33 p.m. intravenously for a pain score of nine (9). A pain re-assessment was not completed for effectiveness.
Patient # 8
Record review on 7/26/2018 of the medical administrative record (MAR) dated 6/20/2018 for Patient (ID#8) revealed one tablet of hydrocodone with acetaminophen was given at 5:06 p.m. by mouth for a pain score of ten (10). A pain re-assessment was not completed for effectiveness.
Patient # 9
Record review on 7/26/2018 of the medical administrative record (MAR) dated 6/20/2018 for Patient (ID#9) revealed Morphine 4 mg was given at 6:08 p.m. intravenously for a pain. A pain re-assessment was not completed for effectiveness.
Interview on 7/26/2018 between 1030 and 1145 with charge nurse (staff #55). she stated "reassessments (of pain medications) should be completed one (1) hour after giving PO (medication by mouth) and 30 minutes for IV" (intravenous) pain medication.
Record review of facility policy titled Pain Assessment and Management in the Adult Population dated: 10/2/2015 stated: The effectiveness of pharmacological interventions will be reassessed/monitored and documented in the EMR (electronic medical record).
Oral medications: 1-1.5 hours after administration
IM/SQ/IV (intramuscular, subcutaneous, intravenous) medications: 30-60 minutes after administration.