HospitalInspections.org

32670


Based on record review and interview, the facility failed to ensure patients receive effective pain management in 7 of 10 (# 1, 2, 4, 6, 7, 8, and 10) patients receiving pain management. This deficiency has the potential to affect all patients experiencing pain who are treated at this facility.

Findings include:

Review on 7/22/2014 at 10:00 AM, of facility policy titled Pain Management # Nsg 4000 dated 1/2/07, it states under Ongoing Pain Assessment/Reassessment, "Ongoing Pain assessment/reassessment ...2. Must occur prior to next intervention" and "8. Reassessment... as recommended in the Acute and Chronic Clinical Practice: Intravenous Medications - 30 minutes: Intramuscular medication - 60 minutes: Oral Medications - 60 minutes."

Per interview on 7/21/14 at 1:40 PM with Quality Improvement Nurse K, Nurse K stated that the expectation is for pain assessments to occur at the time of administration of pain medication followed by a pain reassessment in 30 minutes for intravenous medications and 60 minutes for oral medications.

Per interview with Nurse Educator G on 7/22/14 at 12:20 PM, Nurse Educator G stated pain assessment and pain medication reassessment per policy is a concern at this hospital. Nurse Educator G acknowledged that staff are not completing the required re-assessment after pain medications are given.

Review of Pt #1's MR on 7/21/14 at 2:00 PM accompanied by Quality Improvement Nurse K, revealed Pt #1 received Loritab (oral pain mediation) on 4/4/14 at 12:43 PM and 7:31 PM. There is no documentation of pain reassessment within 60 minutes of administration.

Review of Pt #2's MR on 7/21/14 at 3:00 PM accompanied by Quality Improvement Nurse K, revealed Pt #2 received Oyxcodone (oral pain medication) on 6/29/14 at 12:39 PM and on 6/30/14 at 7:24 AM. There is no documentation of pain reassessment within 60 minutes of administration. Pt #2 also received Loritab on 6/29/14 at 10:39 PM and there is no documentation of pain assessment at the time of administration or within 60 minutes of administration.

Review of Pt #4's MR on 7/21/14 at 3:30 PM accompanied by Quality Improvement Nurse K, revealed Pt #4 received Tylenol (oral pain mediation) on 6/29/14 at 4:33 AM. There is no documentation of pain reassessment within 60 minutes of administration.

Review of Pt #6's MR on 7/21/14 at 2:15 PM accompanied by Quality Improvement Nurse L, revealed Pt. #6 received Dilaudid (oral pain medication) on 5/6/14 at 11:30 AM. There is no documentation of pain reassessment within 60 minutes of administration. Pt. #6 also received Oxycodone (oral pain medication) on 5/6/14 at 1:52 AM, 6:17 AM, 11:40 AM, 3:04 PM. On 5/7/14 at 6:12 PM received the same medication. On 5/8/14 at 7:56 AM and 1:01 PM pt. # 6 received the same pain medication. On 5/9/14 at 5:58 AM, 11:36 AM, 3:31 PM and 7:29 PM received the same pain medication. There is no documentation of pain reassessment within 60 minutes of administration.

Review of Pt. #7's MR on 7/21/14 at 4:00 PM accompanied by Quality Improvement Nurse L, revealed Pt. #7 received Dilaudid (oral pain medication) on 6/24/14 at 3:43 PM and 10:57 PM. On 6/25/14 received the same medication at 5:08 AM and 12:44 PM. There is no documentation of pain reassessment within 60 minutes of administration.

Review of Pt #8's MR on 7/22/14 at 8:30 AM accompanied by Quality Improvement Nurse K, revealed Pt #8 received Toradol (intravenous pain medication) on 6/20/14 at 3:59 AM, 1:29 PM, and 10:16 PM. There is no documentation of pain reassessment within 60 minutes of administration. Pt #8 also received Toradol at 7:01 PM on 6/19/14 and there is no documentation of pain assessment at the time of administration or within 30 minutes of administration. Pt #8 received Loritab (on oral pain medication) on 6/21/14 at 12:17 AM and 12:31 PM. There is no documentation of pain reassessment within 60 minutes of administration.

Review of Pt #10's MR on 7/22/14 at 9:00 AM accompanied by Quality Improvement Nurse K, revealed Pt #10 received Fentanyl (intravenous pain medication) on 5/2/14 at 12:19 AM. There is no documentation of pain assessment at the time of administration or within 30 minutes of administration. Pt # 10 also received Loritab (oral pain medication on 5/3/14 at 7:50 PM, and on 5/4/14 at 3:58 PM and 9:35 PM and there is no documentation of pain assessment at the time of administration or within 60 minutes of administration.

32670


Based on record review and interview, the facility failed to ensure consents are signed, dated and timed prior to the procedure in 2 of 6 (#1, 8) records containing informed consents out of a total universe of 10 records reviewed. This deficient practice has the potential to affect all patients consenting to a procedure.

Findings include:

Review on 7/22/14 at 9:45 AM of facility policy titled "Informed Consent #GL-6039", undated, it states under Signing and Witnessing Permission Forms "A witness attesting to the genuineness of the patient or patient representative's signature should sign and date the form."

During review of Pt #1's MR on 7/21/14 at 2:00 PM, noted a consent for a transrectal ultrasound and prostate biopsy (insertion of a needle through probe in the rectum to remove prostate tissue for testing) signed by Pt #1 and MA N on 3/31/14 but did not include the time the consent was signed by the patient or witness.

During review of Pt #8's MR on 7/22/14 at 8:30 AM, noted a consent for left external fixation femur and tibia (placement of metal pins into the broken thigh bone and larger bone in the lower leg) signed by Pt #8 on 6/19/14 and witnessed by RN O but did not include the time the consent was signed by the patient or witness.

During interview on 7/22/14 at 8:45 AM, Clinical Manager M stated the expectation is that staff document the time they witness the patient sign the consent prior to any procedure.

During interview on 7/21/14 at 3:30 PM, while discussing Pt #1's consent and Pt #8's consent for a prostate biopsy Continuous Readiness Director A stated "they should be timed."