HospitalInspections.org

21980

Based on surveyor observation, record review and staff interview, it has been determined that the hospital failed to evaluate the nursing care for 2 of 2 relevant sample patients (ID#'s 1 & 8) relative to pain.

Findings are as follows:

A. The hospital Clinical Skills policy relative to Dry and Moist-to-Dry Dressing states, in part:

5. Determine the patient's level of comfort using an organization-approved pain scale.
10. Administer prescribed analgesic as needed before dressing change.
11. Reassess the patient's pain status, allowing for sufficient onset of action per medication, route, and the patient's condition.

Medical record review for patient ID# 1 revealed he/she is cognitively impaired with a diagnosis of intellectual disability. The patient was admitted to the hospital on 9/11/2015 for the treatment of wound infections.

There is a current physician's order dated 9/16/2015 to administer Ibuprofen 400 milligrams (mg), 1 tablet by mouth every 4 hours as needed for pain. The patient also has a current physician's order dated 9/16/2015 to administer morphine 2 mg intravenous push, every 4 hours as needed for pain.

The dressing changes to the patient's leg wounds were observed on 9/16/2015 at 9:30 AM. During removal of the dressings and cleaning of the wound bed, the patient was repeatedly grinding his/her teeth, clenching his/her hands and repeatedly stating "ouch, ouch, easy, easy ...". The nurse continued with the dressing change and did not address the patient's pain at this time.

Record review and interview with the above nurse on 9/16/2015 at 11:00 AM revealed no evidence that the patient received any pain medication prior to the dressing changes. The nurse stated that she should have stopped the dressing change and ensured that the patient was medicated for pain prior to continuation of the dressing changes.

B) The hospital Policy/Procedure titled "Pain Management", last modified on 4/2012, states in part, under Procedure:

Assessment/Reassessment

2. All patient will be screened for the presence of pain every shift.
3. With each new report of pain, the nurse will assess the patient.

During surveyor observation on 9/21/2015 at 9:10 AM, patient ID #8 stated to the nurse (staff A) that he/she was not "in a good mood" because he/she has pain and "sometimes it is really bad".

Medical record review revealed this patient was admitted to the hospital on 9/13/2015. On 9/20/2015 at 4:13 PM, the patient indicated foot pain with a pain scale of 10 out of 10. Per the hospitals computerized medical record system, a "Pain Assessment Adult" tool, is to be utilized when a patient reports and is medicated for pain. There lacked evidence that the patient had been assessed for 16 of the 18 pain indicators, including:

Acceptable Pain intensity
Primary Pain Laterality
Primary Pain Onset
Primary Pain Duration
Primary pain Quality
Primary Pain Time Pattern
Primary Pain Radiation
Pain Associated Symptoms
Primary Pain Aggravating
Primary pain Alleviating
Pain Negatively Impacts
Primary pain Interventions
Additional Pain Sites

When questioned on 9/21/2015 at 9:10 AM, the Clinical Manager (staff B) was unable to produce evidence that this patient has been assessed relative to pain.

Additionally, the hospital Policy/Procedure titled "Pain Management" last modified on 4/2012, states, in part, under Pharmacologic Interventions:

1. Offer medications according to L.I.P. (Licensed Independence Practitioner) orders ...
2. If multiple pain medications are ordered ....
b) Patient with a numeric pain scale score of 4-7: (moderate pain): administer prn (as needed) medication indicated for moderate pain.
c) Patient with a numeric pain scale score of 8-10: (severe pain): administer prn medication indicated for severe pain.

The patient has a physician's order dated 9/16/2015 for Acetaminophen-Hydrocodone (Vicodin) 5/325 milligram (mg) 1 tablet by mouth, every 8 hours as needed for moderate pain.

On 9/20/2015 at 4:13 PM, the patient indicated he/she had foot pain with a pain scale of 10 out of 10. Review of the Medication Administration Record revealed the patient received Vicodin 1 tablet on 9/20/2015 at 4:13 PM, which was ordered to address moderate pain of 4-7 instead of the required medication which would address a pain scale of 8-10.

During an interview on 9/21/2015 at 9:10 AM, the Clinical Manager (staff B) stated the physician's order indicates Vicodin is for moderate pain, therefore, the nurse should not give the medication per physician's order.

Based on surveyor observation, record review and staff interview, it has been determined that the hospital failed to develop a nursing care plan for 2 of 2 relevant sample patients (ID #'s 1 & 8) relative to pain.

Findings are as follows:

A) Medical record review for patient ID# 1 revealed he/she is cognitively impaired with a diagnosis of intellectual disability. The patient was admitted to the hospital on 9/11/2015 for the treatment of wound infections.

A physician progress note dated 9/16/2015 indicates the patient has bilateral lower leg wounds which appears to be chronic venous insufficiency. The wounds are "extremely weeping and edema of the wounds ..." and the patient "is very noncompliant and gets agitated if any one touches his/[her] legs".

The dressing changes to the patient's leg wounds was observed on 9/16/2015 at 9:30 AM. During removal of the dressings and cleaning of the wound bed, the patient was repeatedly grinding his/her teeth, clenching his/her hands and repeatedly stating "ouch, ouch, easy, easy ...". When questioned during this observation, the nurse (staff C) stated the patient received morphine 2 mg at 8:30 AM.

Further record review revealed that, although the patient is assessed and medicated for pain, there is no evidence that a care plan relative to pain was developed.

When questioned on 9/21/2015 at 9:10 AM, the Clinical Manager (staff D) was unable to produce evidence that a care plan for pain had been developed.

B) Medical record review for patient ID# 8 revealed that on 9/20/2015 at 4:13 PM, the patient indicated foot pain with a pain scale of 10 out of 10.

During surveyor observation on 9/21/2015 at 9:10 AM, the patient stated to the nurse (staff A) that he/she was not "in a good mood" because he/she has pain and "sometimes it is really bad".

Further record review failed to reveal that a care plan was developed to address this patient's foot pain.

When questioned on 9/21/2015 at 9:10 AM, the Clinical Manager (staff B) was unable to produce evidence of a care plan for pain.

21980

Based on record review and staff interview, it has been determined that the hospital failed to administer medication in accordance with a physician's order for 1 of 1 sample patient's (ID # 1) who complained of pain.

Findings are as follows:

Medical record review for patient ID# 1 revealed he/she is cognitively impaired with a diagnosis of intellectual disability. The patient was admitted to the hospital on 9/11/2015 for the treatment of wound infections.

There is a current physician's order dated 9/16/2015 to administer Ibuprofen 400 milligrams (mg), 1 tablet by mouth, every 4 hours as needed for pain. The patient also has a current physician's order dated 9/16/2015 to administer morphine 2 mg intravenous push, every 4 hours as needed for pain.

The dressing changes to the patient's leg wounds was observed on 9/16/2015 at 9:30 AM. During removal of the dressings and cleaning of the wound bed, the patient was repeatedly grinding his/her teeth, clenching his/her hands and repeatedly stating "ouch, ouch, easy easy ... ". The nurse continued with the dressing change and did not address the patient's pain at this time.

Record review and interview with the above nurse on 9/16/2015 at 11:00 AM revealed no evidence that the patient received any pain medication prior to the dressing changes. The nurse stated that she should have stopped the dressing change and ensured that the patient was medicated for pain per physician's order.

Based on surveyor observation, record review and staff interview, it has been determined that the hospital failed to use appropriate personal protective equipment including gowns, and gloves according to their Infection Prevention Policy and Procedure for 2 of 3 relevant patients (ID #'s 1 & 11).

Findings are as follows:

I. The hospital Policy and Procedure relative to Dry and Moist-to-Dry dressing indicates, in part:

14. Remove tape, gauze, wrap bandage,...
18. Fold dressing with drainage contained inside,... and remove gloves
inside out,.. and discard gloves with soiled dressing,...
19. Perform hand hygiene and don clean gloves...
21. Cleanse the wound...
23. Remove gloves and perform hand hygiene...
24. Apply dressing...

II. The hospital Policy and Procedure relative to Contact Isolation Precaution indicates: "Gloves and gowns are required to enter room."

A) Medical record review for patient ID # 1 revealed the patient was admitted to the hospital on 9/11/2015 for treatment of wound infections. The patient has a history of Methicillin Resistant Staphylococcus Aureus (a bacterium responsible for several difficult-to-treat infections in humans) in the leg ulcers and therefore, the patient is on contact isolation precautions.

A physician progress note dated 9/16/2015 indicates the patient has bilateral lower legs wounds which appear to be chronic venous insufficiency. The wounds are "extremely weeping..."

During surveyor observation of the dressing change to the right leg on 9/16/2015 at 9:30 AM, staff C removed the soiled dressing and, without removing her soiled gloves, she processed to cleanse the wound.

When the right leg wound dressing change was complete, the nurse removed her soiled gloves, did not perform hand hygiene before donning a new pair of gloves and proceeded to conduct the dressing change on the left leg wound. Again, staff C removed the soiled dressing and, without removing her soiled gloves, she processed to cleanse the wound with the same soiled gloves.

Surveyor noted that during the above observations, the patient was touching the soiled dressing and (with the nurse assisting him) cleansing, and applying clean gauzes to the wounds on his/her legs. During this observation, the nurse did not offer/instruct the patient to do hand hygiene before or after the dressing change. This patient was observed touching his/her ear, nose and mouth during these dressing changes.

Additional surveyor observation on 9/21/2015 at 11:15 AM revealed two nurses (staff C and E) were in the room with this patient. Staff C, who was standing next to the patient, was not wearing either a gown nor gloves and staff E, who was working on the computer, was not wearing a gown.

When questioned on 9/21/2015 at 11:45 AM, the Clinical Manager (staff D) was unable to produce evidence that the infection control policy and procedure had been implemented relative to dressing changes and isolation precautions.

III. The hospital Policy and Procedure for Infection Prevention Policy, entitled Hand Hygiene indicates, in part, under Procedure:

Hand Hygiene (cleaning the hands using soap and water or alcohol-based hand sanitizer) is required.

1. Before and after having direct contact with patients or inanimate objects in their immediate environment, including medical equipment..."

B) Surveyor observation on 9/21/2015 at approximately 10:30 AM revealed patient ID #11 receiving dialysis treatment. The patient's nurse (staff F) was observed adjusting the IV line and the settings to the dialysis machine with bare hands. She proceeded to document on a piece of paper which was on the bedside table. She then went to the nursing station and worked on the computer. The nurse did not perform hand hygiene after touching the dialysis machine.

During an interview with the Clinical Manager (staff G) on 9/21/2015 at 10:55 AM, staff F indicated that she wears gloves and performs hand hygiene only after touching a dialysis machine that is used by a patient who is on isolation precautions.