HospitalInspections.org

Based on record review and interview, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for each patient in accordance with the patient's needs, in that,

There was no documented patient response/nursing re-assessment after pain medication administration for 1 of 9 patients (Patient #1) reviewed;

There was no verification of patient allergies documented prior to pain medication administration for 1 of 9 patients (Patient #1) reviewed; AND

There was no documented patient response/nursing re-assessment after Narcan administrations for 3 of 9 patients (Patient #1, #2, and #3) reviewed.

Findings were

Patient #1 received pain medication and Narcan on 5/26/2018. Family was present. Patient #1's allergies were documented 4/18/2018, and not re-verified prior to the 5/26/2018 medication administration.

Patient #2 received Narcan on 4/28/2021.

Patient #3 received Narcan on 4/24/2021.

There was no documented patient response/nursing re-assessment after any of the administrations of the above medications.

During an interview and record review on 4/28/2021 at 1:05 PM, Personnel #4 navigated the electronic records and confirmed the above findings.

During an interview on 4/28/2021 ending at 2:39 PM, Personnel #3 stated, "PRN medication follow-up is expected for all medications." Personnel #3 pointed out re-assessment is required in the policy.

During an interview on 4/28/2021 at 3:10 PM, Personnel #1 stated, "I followed up with the Director of the ER about re-assessment after Narcan administration. Narcan is considered an intervention - re-assessment would be expected to be documented."

The facility's "Assessment/Re-Assessment" policy required, "individualized care/treatment/services...Reassessment - Further data collection and analysis, the scope of which is determined by the patient's diagnosis, the treatment setting, the patient's desire for treatment, and the patient's response to treatment...administration of pain control medications and during/after procedures to determine effectiveness..."