HospitalInspections.org

Based on facility pain policy reviews, medical record reviews, and staff interviews, the facility failed to evaluate pain thoroughly, failed to follow up on effectiveness of pain interventions, and failed to follow pain policies in 2 of 2 patients with pain from a total sample of 3 patients (Patients #1 and #2).
Findings include:
Per review of facility pain policies beginning at 1:45 p.m. on 1/13/09, the following was noted:
Pain management policy index #Nsg.-4000 states that when pain is present, the patient will be offered appropriate interventions. When an intervention is utilized, the patient will be reassessed for effectiveness of the intervention. Comprehensive assessments will be completed within 12 hours of admission. If pain is present: determine pain scale (severity), orientation (right or left), location, radiation, acceptable comfort level, frequency, quality, and factors that affect and relieve pain.
For ongoing pain assessments, assessments will be completed every shift (minimally twice in 24 hours) or more frequently as patient condition warrants. When an intervention is utilized, the patient will be reassessed for effectiveness of the intervention. If no intervention is utilized when pain is present, acceptable comfort level will be assessed.
Policy index #GL-6163 entitled Medication Management Adult Patient Controlled Analgesia PCA (Patient Controlled Analgesia) using a pump states the following: Within 30 minutes of pump initiation or dosage change, patient's response to intervention will be assessed and documented. Minimally every 4 hours patient will have ongoing pain assessment.
(1.) Per medical record review of Patient #1 by Surveyor #05409 and Nursing Specialist "A" from 10:50 a.m. to 11:45 a.m. on 1/13/10, the following was noted and verified by "A" via interview during the review:
Patient #1 came into the E.D. (emergency department) by ambulance at 2:53 a.m. on 8/2/09. Pain was first evaluated at 2:56 a.m. The evaluation stated that Patient #1 had right leg pain of 10 out of a 0 to 10 scale, with 10 being the worst. No other pain characteristics of the pain were evaluated. The evaluation was incomplete. Patient #1 was given 4 mg of Morphine IV (intravenously) at 3:22 a.m. on 8/2/09. There was no follow up evaluation of the Morphine effectiveness, but Patient #1 was given another 4 mg of Morphine via IV at 4:15 a.m. on 8/2/09. There were no other pain evaluations in the E.D. An x-ray of Patient #1's right leg revealed an oblique fracture of the lower third of the shaft of the right femur.
On 8/2/09 at 4:55 a.m., Patient #1 was admitted to 3rd floor. Nursing evaluation of Patient #1's pain at 5:00 a.m. stated that right leg pain was 10 out of 10, constant, aching, and radiated to the right knee. Patient #1 was given 3 mg of Morphine via IV at 5:19 a.m. on 8/2/09. No follow up evaluation of the Morphine effectiveness was done as per policy.
The next pain evaluation was not done until 6:12 a.m. on 8/2/09. Patient #1 complained of right leg pain of 8 out of 10. No pain interventions were documented as done at this time. Patient #1 was placed on a pain pump at 7:48 a.m. on 8/2/09 with patient able to press pump to administer 1 mg of Morphine every 10 minutes as needed.
The next pain evaluation was done at 10:22 a.m. on 8/2/09. Nursing evaluation revealed that Patient #1 continued to have right leg pain of 8 out of 10 at rest, 10 out of 10 with activity, Patient crying and tensing muscles. No other pain relief measures were done (Patient on the pain pump).
The next pain evaluation was done at 1:00 p.m. on 8/2/09 and revealed that Patient #1 continued to have right leg pain of 8 out of 10 at rest, 10 out of 10 with activity, Patient crying, grimacing, and tensing muscles. Nursing gave Patient #1 Tylenol 650 mg at 1:12 p.m.
The next pain evaluation at 3:00 p.m. on 8/2/09 revealed that right leg pain had decreased to 5 of 10 at rest and 8 of 10 with activity, but Patient crying, grimacing, and tensing muscles. No further pain interventions were done.
A physician wrote an order at 3:21 p.m. on 8/2/09 to discontinue the pain pump and wrote orders for pain medication of Lortab 500 mg 1 to 2 tablets as needed for pain. (other as needed pain medications included Tylenol 650 mg and Oxycodone 1 to 2 5 mg tablets).
The next pain evaluation was done at 4:00 p.m. on 8/2/09 and revealed that Patient #1 had right leg pain of 5 at rest and "11" with activity (greater than 10 out of 10). Patient #1 crying, grimacing, and guarding.
Lortab 2-500 mg tablets were given to Patient #1 at 4:06 p.m. Additional pain medications were also given during the evening and early morning 8/3/09.
The pain evaluation done at 12:56 p.m. on 8/3/09 revealed right leg pain at rest 6. Nursing administered 10 mg Oxycodone. There was no evaluation of its effectiveness. The next pain evaluation was done at 3:05 p.m. and stated that pain at rest increased to 8. Given 650 mg of Tylenol at 3:22 p.m. There was no evaluation of its effectiveness.
Per review of the medication administration record Patient #1 was given 10 mg of Oxycodone at 9:08 p.m. on 8/3/09, but there was no pain evaluation done at that time.
Per nursing evaluation of pain at 1:00 a.m. on 8/4/09, 10 mg of Oxycodone was given at 1:07 a.m., but there was no evaluation of its effectiveness until 5:21 a.m.
No pain evaluation revealed what was an acceptable pain level for Patient #1 until the evaluation at 8:00 a.m. on 8/4/09 (greater that 48 hours after admission).
Per review of medication administration, it was noted that nursing gave Patient #1 2 mg of IV Morphine at 10:27 a.m. on 8/4/09, but nursing did not do a pain evaluation at that time.
The last pain assessment completed by nursing staff was done at 11:24 a.m. on 8/4/09 when Patient #1 complained of pain at 6 in the right leg with activity. Nursing staff administered 5 mg of of Oxycodone at 11:29 a.m.
Per review of medication administration, Patient #1 was given 650 mg of Tylenol at 1:19 p.m. and 5 mg of Oxycodone at 1:24 p.m. on 8/4/09, but there was no pain evaluation done at either time.
Per occupational therapy documentation at 11:36 a.m. Patient #1 missed the therapy session. Patient #1 cancelled the session because she was in too much pain.
Patient #1 was discharged from the facility at 3:38 p.m. on 8/4/09. There was no evaluation by nursing staff in regard to pain and effectiveness of pain medications last given at 1:19 p.m. and 1:24 p.m. as above.
(2.) Per medical record review of Patient #2 by Surveyor #05409 and Nursing Specialist "A" from 7:35 a.m. to 10:40 a.m. on 1/13/10, the following was noted and verified by "A" per interview during the review:
Patient #2 arrived in the E.D. at 3:31 p.m. on 11/9/09 and at 3:41 p.m. pain was evaluated at 7 out of 10 at rest in the right wrist. No further pain characteristics were evaluated. The pain evaluation was incomplete. At 3:45 p.m. Patient #2 complained of left ankle pain, but an evaluation of the ankle pain was not done. Radiology reports revealed a fractured right wrist and surgery was done on the wrist. Patient #2 was then admitted to 3rd floor around 11:00 p.m. on 11/9/09. A PCA (pain pump) was set up at 12:15 a.m. on 11/10/09.
At 12:46 a.m. on 11/10/09 Patient #2 reported right arm pain of 8 out of 10 and acceptable level of pain 4. Nursing did another pain evaluation at 3:32 a.m.
The next pain evaluation was not done until 10:20 a.m. on 11/10/09 (approximately 7 hours later). Nursing staff did not evaluate the pain every 4 hours as per policy. When the evaluation of pain was done at 10:20 a.m., location of pain was not evaluated. The evaluation was incomplete.
The PCA pump was removed at 1:00 p.m. on 11/10/09. At 1:52 p.m. Patient #2 complained of left hip pain of 3 at rest and 6 with activity during a Physical Therapy session. Nursing documented at the same time that Patient #2 had pain of 5 at rest and 8 with activity, but location of the pain was not evaluated.
At 5:42 a.m. on 11/11/09 nursing staff evaluated that Patient #2 had left hip pain of 4 and was given 2 Lortab tablets at 6:01 p.m. There was no follow up evaluation of the effectiveness of the Lortab. The next pain evaluation was done at 1:28 p.m. and does not include pain location or orientation as per policy.
On 11/12/09 at 1:25 a.m. pain was evaluated and Lortab was administered for pain, but there was no follow-up evaluation of the effectiveness. Per medication administration review, Patient #2 was given 1 Lortab for pain at 11:19 p.m. on 11/12/09, but the effectiveness was not evaluated.
Patient #2 had left hip surgery on the morning of 11/13/09 and returned to 3rd floor at 3:28 p.m. 11/13/09. A pain evaluation done by nursing staff at 3:00 p.m. on 11/17/09 does not include pain location or orientation.