HospitalInspections.org

Based on review of facility policy, review of medical records (MR), and interview with staff (EMP), it was determined that facility staff failed to assess patient's care needs and response to interventions as required by facility policy for one of three patients with pain (MR1) and failed to document weekly vital signs for three of seven patients (MR1, MR3 and MR4) .

Findings include:

Review of " Nursing Policy No. 85-90 Date February 10, 2010, Torrance State Hospital Policy/Procedure for the Nursing Process" revealed "Attachment H Torrance State Hospital Pain Management Guidelines Policy: The RN, and clinical staff as members of the multidisciplinary treatment team, will be responsible to assess risk for pain and recognize the subjectivity of each patient's definition of pain. Each patient has the right to effective management of pain. .... Guidelines: ... 8. With acute pain, status is to be documented per shift in Progress Note. 9. Document all pain assessment on Pain Management Flow Sheet. ..."

Review of " Nursing Policy No. 85-133 Date December 2, 2010, Torrance State Hospital Policy/Procedure for Vital Signs" revealed "...A. Taking and recording vital signs is a nursing order based on assessment by the registered nurse...B. General guidelines for implementing nursing orders as follows: 1. All patients weekly at 9 AM on Saturday. ..."

Review of facility policy/procedure "Vital Signs" approved December 13, 2010, revealed "...Record vital signs in progress as indicated and on form wf-225 (Weekly Vital Signs And Monthly Weights Form)..."

1) Review of MR1 patient's "Progress Report" revealed "To office @ 1:30 AM c/o (complaint of) upper abdominal discomfort 10/10. ... ordered Tramadol 50 mg (pain medication) po (by mouth) now, given @ 2:05 AM Will continue to observe for affect."

Continued review of the "Pain Management Flow Sheet" revealed no documentation of the patient's pain assessment on the sheet.

Interview with EMP5 on May 17, 2011, at 12:45 PM confirmed that there was no documentation of the pain assessment on the Pain Management Flow Sheet for MR1.

Review of " Nursing Policy No. 85-133 Date December 2, 2010, Torrance State Hospital Policy/Procedure for Vital Signs" revealed "...A. Taking and recording vital signs is a nursing order based on assessment by the registered nurse...B. General guidelines for implementing nursing orders as follows: 1. All patients weekly at 9 AM on Saturday. ..."

Review of facility policy/procedure "Vital Signs" approved December 13, 2010, revealed "...Record vital signs in progress as indicated and on form wf-225 (Weekly Vital Signs And Monthly Weights Form)..."

2) Review of MR3 and MR4 revealed that the weekly vital signs were not documented in the progress notes or on form wf-225.

Interview with EMP1 on May 17, 2011, at 3:00 PM confirmed that there was no documentation of weekly vitals signs in the progress notes or on form wf-225 for MR3 or MR4.

3) Review of MR1 revealed that the weekly vital signs were not documented on the form wf-225.

Interview with EMP5 on May 17, 2011, at approximately 12:45 PM confirmed that there was no documentation of the weekly vital signs on the form wf-225 for MR1.