HospitalInspections.org

Based on medical record review, policy review and staff interviews, the facility failed to ensure nursing staff documented pain assessments and interventions per policy. This affected three (Patient #2, #6 and #10) of 10 patients' medical records reviewed. The census at the time of entrance was 191.

Findings include:

1. Facility policy Pain, Adult (P-29) was reviewed. Per said policy a "pain history" was to be obtained at the time of admission and a then "a complete reassessment once within every 8 hour shift, MUST include 3 descriptors, including location and intensity." This information was to be documented in the medical record, along with "interventions/comfort measures used", "medication administered" and a "complete reassessment within 30 minutes prior to giving a pain medication and within 1 hour post-intervention(s) minimally with a pain intensity score."

2. Review of the medical record for Patient #2 revealed on 04/11/15 at 5:12 AM, Patient #2 reported pain as continuous left sided abdominal pain with a score of 9/10 (score of 9 using a scale of 1 to 10 with 10 being the worse pain ever). Review of the medication administration record (MAR) revealed Patient #2 received Morphine Sulfate (opioid pain medication) 2 milligrams (mg) at 5:12 AM on 04/11/15. Patient #2 was not assessed for pain until 8:22 AM on 04/11/15. At that time, Patient #2 reported pain as 5/10, lower abdominal pain. Review of the MAR indicated Patient #2 received Morphine Sulfate 2 (mg) at 8:22 AM. A pain assessment was not done for Patient #2 until 11:42 AM on 04/11/15, over three hours later.

Staff C confirmed the above findings on 07/16/15 at 11:30 AM.

3. The medical record for Patient #6 revealed the patient was admitted on 07/11/15 with a diagnosis of abdominal pain. On 07/11/15 at 1:26 AM, Patient #6 reported abdominal pain, 8/10. An order was obtained, and Patient #6 received 1 mg of Dilaudid (potent opioid pain medication) IV at 2:27 AM. There was no documented re-assessment of Patient #6 following this administration until 1:08 PM, approximately 10.5 hours later. At that time, Patient #6 reported pain 6/10. There was no indication of where the pain was or the quality of the pain.

Patient #6's next documented pain assessment was at 10:42 PM, at which time it was reportedly 5/10. There was no indication of the location of quality of the pain.

On 07/13/15 at 11:32 AM, Patient #6 reported a pain score of 8/10, but there was no indication of the location or quality of the pain. Patient #6 was medicated at 11:33 AM with 1 mg of Dilaudid IV. There was no documented re-assessment of Patient #6 following this administration until 07/14/15 at 12:10 AM, approximately 13 hours later.

On 07/14/15 at 10:28 PM, Patient #6 reported a pain score of 7/10, but there was no indication of the location or quality of her pain.

4. The medical record for Patient #10 revealed the patient was admitted on 07/09/15 with a diagnosis of acute, upper right abdominal pain. On 07/11/15 at 2:44 PM, Patient #10 reported pain 7/10, but there was no indication of the location or quality of the pain. The patient was medicated with 2 mg of morphine IV, but there was no documented re-assessment of Patient #10 until 6:26 PM at which it was reportedly 10/10. The patient was medicated with 2 mg of Dilaudid IV at that time. Patient #10 was reassessed at 7:00 PM, but there was no indication of the location or quality of her pain.

Patient #10's pain was not re-assessed until 07/12/15 at 5:14 AM, at which time it was reportedly 8/10. There was no indication of the location or the quality of the pain. Patient #10 received 2 mg of Dilaudid IV at that time, but he/she was not re-assessed following this administration until 7:18 AM.

On 07/13/15 at 8:32 PM, Patient #10 reported a pain score of 9/10, and the patient was medicated with 2 mg of Dilaudid IV. There was no re-assessment following this administration until 7:07 AM on 07/14/15, approximately 10.5 hours later.

On 07/15/15 at 10:55 AM, Patient #10 reported a pain score of 8/10, and again at 11:04 AM the patient's pain was still 8/10. There was no documented evidence Patient #10 was medicated for this reported pain. Patient #10's pain was not addressed until 2:02 PM, at which time he/she received 2 mg Dilaudid IV.

Staff D was made aware of and confirmed the above findings on 07/16/15 at 8:54 AM.

Based on medical record review, policy review and staff interviews, the facility failed to ensure the patients' plan of care addressed all identified and current patient problems. This affected two (Patient #2 and #6) of 10 patients' medical records reviewed. The current census was 191.

Findings include:

Facility policy Patient Plan of Care (TX-13), revealed "an interdisciplinary plan of care is formulated on patients within 24 hours of admission. The registered nurse (RN) develops the patient plan of care in collaboration with the patient, significant other(s), and other health team members."

The policy also stated the plan of care was "initialized and defines patient care" and was to be evaluated daily. The following information was to be used to develop the patient's plan of care, the initial assessment, the physical assessment, the interdisciplinary patient/family teaching record and treatment information.

1. Review of the medical record for Patient #2 revealed the patient was admitted on 04/11/15 at 12:53 AM with an intestinal obstruction. Review of the MAR revealed Patient #2 received four doses of Morphine Sulfate (MS) 2 milligrams (mg) intravenously (IV), seven doses of MS 4 mg IV and two doses of Dilaudid 2 mg IV for pain from 04/11/15 to 04/12/15. Review of the care plan for Patient #2 revealed a care plan for pain was not identified and addressed for this patient.

Staff C confirmed this finding on 07/15/15 at 4:35 PM.

2. The medical record for Patient #6 revealed the patient was admitted on 07/11/15 with a diagnosis of abdominal pain. During the course of the patient's hospitalization between 07/11/15 and 07/15/15, Patient #6 was medicated for complaints of pain seven times. Patient #6 received three doses of 0.5 mg Dilaudid IV, three doses of 1 mg Dilaudid IV and one dose of 30 mg Toradol IV.

The patient plan of care for Patient #6 failed to identify and address the patient's pain. Staff D was made aware of and confirmed these findings related to Patient #6 on 07/16/15 at 8:54 AM. At that time, Staff D also confirmed pain should have been part of the patient's plan of care.

Based on medical record review and staff interviews, the facility failed to ensure medications were administered as ordered by the physician. This affected one (Patient #2) of 10 patients' medical records reviewed. The current census was 191.

Findings include:

Review of the medical record for the Patient #2 revealed the patient had physician's orders, dated 04/11/15, for Morphine Sulfate 2 milligrams (mg) intravenous (IV) every two hours for moderate pain (4-6 on pain scale) and Morphine Sulfate 4 mg, IV, every two hours for severe pain (7-10 on pain scale). Review of the pain assessment for Patient #2 revealed the patient reported a pain score of 9 on 04/11/15 at 3:09 AM and 5:12 AM. Review of the medication administration record (MAR) revealed Patient #2 received an IV dose of Morphine Sulfate 2 mg on 04/11/15 at 3:09 AM and 5:12 AM, not the ordered 4 mg for severe pain. Review of the pain assessment for Patient #2 revealed the patient reported a pain score of 10 on 04/11/15 at 8:56 PM. Review of the MAR revealed Patient #2 received an IV dose of Morphine Sulfate 2 mg on 04/11/15 at 8:56 PM, not the ordered 4 mg for severe pain.

Staff C confirmed these findings on 07/15/15 at 4:35 PM.

Based on medical record review, policy review and staff interviews, the facility failed to ensure staff reported an unexpected occurrence as required by the facility's policy. This affected one (Patient #2) of one sentinel events reviewed. The current census was 191.

Findings include:

Facility policy titled Sentinel Events (PI-07), revealed an occurrence report was to be done immediately. The purpose of this policy was to have a process for identification, reporting, analysis, and prevention of sentinel events.

Review of the medication administration record (MAR) revealed Patient #2 received Dilaudid 2 milligrams (mg) intravenous (IV) at 6:17 AM and 8:38 AM. Review of the nursing progress notes, dated 04/12/15 at 9:15 AM, revealed the primary care physician was at the hospital to see Patient #2. This note revealed the physician informed the registered nurse (RN) that Patient #2 didn't look good. The nursing progress indicated the RN was unable to obtain a pulse oximeter reading, and Patient #2's color was blue. The note further indicated a rapid response team was called.

Review of a note by a consulting physician, dated 04/12/15 at 5:48 PM, revealed Patient #2 was transferred to the Intensive Care Unit the morning after a respiratory arrest. The note indicated Patient #2 had received 2 mg of IV Dilaudid, prior to the event and was found unresponsive in his/her room. The note also indicated Patient #2 had one minute of cardiopulmonary resuscitation, but this was purely a respiratory arrest. Further review of the consulting note indicated Patient #2 was awake and responsive, after receiving Narcan.

Interview with Staff B on 07/16/15 at 10:15 AM confirmed the facility's Risk Management was not aware of this event until 07/01/15, after a complaint was issued to the facility's accrediting organization. Staff B confirmed this adverse event had not been reported as it should have been.