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Based on record review, policy review and staff interview it was determined the Registered Nurse failed to ensure appropriate nursing care related to nursing assessment and implementation of physician orders was provided for 3 (#6, #7, #8) of 10 sampled patients. This practice does not ensure nursing care goals are achieved.

Findings include:

1. Patient #6 was admitted to the facility on 1/30/12 with the diagnosis of rectal bleeding. Review of physician orders revealed an order to transfuse 2 units of Packed Red Blood Cells over 2 hours each.

The facility's policy "Blood and Blood Component Administration" #456, revised 7/09 required that vital signs were to be taken and recorded prior to the transfusion, fifteen minutes after onset of the transfusion and at completion of the transfusion.

The first unit was initiated at 4:00 p.m. Vital signs were recorded at 1:56 p.m. There were no vital signs recorded fifteen minutes after the transfusion was initiated. There were no vital signs obtained at the end of the transfusion. The documentation of the length of time the unit was transfusion was unclear. A narrative note indicated the first unit was completed at 3:00 p.m., which would indicate the unit was transfused over one hour instead of the two hours as ordered.

The nurse manger who was present during the record review on 2/2/12 at approximately 9:30 a.m. confirmed the above findings.


2. Patient #7 was admitted with chronic back pain. The physician wrote an order for Norco 5 milligrams for pain. Review of the patient record revealed the patient received pain medication on 2/1/12 at 5:53 a.m., 11:33 a.m., 2:37 p.m., 6:11 a.m. and 10:39 p.m. He also received pain medication on 2/2/12 at 5:03 a.m. Review of assessment documentation revealed the staff documented medication effectiveness, but failed to document the level of pain as the policy requires.

The nurse manager confirmed the above finding during interview on 2/2/12 at 1:00 p.m.

3. Patient # 8 was admitted to the facility on 1/31/12 with the diagnosis of severe back pain. Review of the physician orders revealed an order for Percocet 2 tablets every 4 hours for pain level of 4 - 6 and Morphine 4 milligrams IV (Intravenous) every 1 hour for pain level 7 - 10. Review of nursing documentation revealed the patient reported a pain level of 6 on a 0-10 scale at 9:00 a.m. on 2/1/12. Percocet was administered. At 11:49 a.m. the patient again reported a pain level of 6. It was too early at that time to administer the medication. However, no pain medication was administered until 5:18 p.m. Percocet was administered. The pain level was 7 and Morphine should have been administered instead of percocet as ordered. The nursing staff failed to reassess the patient regarding pain level for 5 hours, knowing the pain level was 6 and no medication had been administered. The nursing staff also failed to administer the correct medication for the pain level reported.

The above finding was substantiated by the nurse manager on 2/2/12 at approximately 2:00 p.m.


The facility's policy "Pain Management" #P 1/0, revised 1/12 required that the patient's pain was to be assessed using a scale that allows the patient to rate the pain level from 0 (no pain) to 10 (worst pain). The policy also required that the pain level be reassessed following administration of pain medication, allowing for time for the medication to reach its peak effectiveness. Patients who are experiencing pain are to be assessed for pain level every 4 hours.