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Based on record review and staff interview, the facility failed to ensure the right of one patient to refuse treatment was honored. (A130) The effect of this practice resulted in the facility's inablity to ensure that patient rights be protected. A sample of 10 medical ecords were reviewed. The facility census was 176.

Based on record review and staff interview, the facility failed to ensure the rights of one patient (Patient #8) to refuse treatment was honored. A sample of 10 medical records were reviewed. The facility census was 176.

Findings include:

The facility policy titled "Patient Rights and Responsibilities", approved 10/08/18, was reviewed on 01/22/19 at 2:45 PM. According to the policy patient rights information is provided to the patient and/or their surrogate at the time of admission or treatment. Under the patient right titled decision-making, the policy stated that patients have the right to refuse care, treatment, and services to the extent permitted by law, and to be informed of the medical consequences of such refusal.

1. Review of the medical record of Patient #8 revealed the patient presented to the Emergency Department on 10/31/18 at 7:20 AM with complaints of shortness of breath and worsening weakness. The patient was admitted to the Intensive Care Unit with a diagnosis of pneumonia. The patient was treated with antibiotics and breathing treatments and on 11/1/18 he was transferred to 4 West, a medical surgical unit with telemetry. A nursing note on the morning of 11/2/18 stated the patient suddenly went into atrial fibrillation (abnormal heart rhythm) with a heart rate in the 140's. The physician was notified and a cardiologist was consulted. The cardiologist examined the patient and at 9:20 AM ordered Xarelto (medication used to prevent blood clots) 20 mg to be given daily orally with breakfast.

A nursing note composed at 12:23 PM stated the following: "Patient refused Xarelto. Education provided to patient on the importance of a blood thinner with an irregular heart rhythm. Patient stated understanding. Patient stated that he was on Xarelto for a few months previously and that he quit taking it at home because of cost and the commercials. This nurse again stressed the importance of anticoagulation and patient agreed for this nurse to ask MD for an alternate anticoagulant."

The medical record lacked documentation that an alternate medication was prescribed. The Medication Administration Record (MAR) revealed the patient was medicated with Xarelto at 5:14 PM with other medications.

A nursing note at 11:15 PM stated bright red blood was dripping from the right nare of the patient. The patient was also noted to be spitting blood from his/her mouth. Firm pressure was applied to the bridge of the patient's nose. The blood from the patient's nose became heavier and at 11:20 PM, a rapid response was called. A nurse practitioner involved in the rapid response performed chemical cauterization and packed the patient's right nare. An otolaryngologist was also consulted to treat the patient.

A physician progress note on 11/03/18 stated the patient still had some bleeding although it was noted to be "very slow." The note also revealed that the Xarelto had been held that day.

Review of a nursing note on 11/03/18 at 9:15 AM stated a physician was notified of "patient refusal of Xarelto."

A progress note composed by the otolaryngologist (doctor who specializes in conditions of the ear, nose and throat) on 11/05/18 stated the plan was to remove the nose packing on 11/06/18. The note by the otolaryngologist on 11/06/18 recommended staff observe the patient overnight and if no further epistaxis (bleeding from the nose) occurred, to discharge the next day. The patient was discharged on 11/7/18.

Staff B, Quality Improvement Coordinator, was interviewed on 01/23/19 at 11:30 AM. It was confirmed that the patient had the right to refuse the prescribed medication.

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Based on record review and staff interview the facility failed to ensure nursing staff assessed and managed pain for eight of 10 patients reviewed. (Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #8, Patient #10, and Patient #11). The facility census was 176.

Findings include:

The facility policy titled "Pain Management", approved 01/07/19, was reviewed on 1/24/19. According to the policy "pain is subjective and the patient's self-reported pain level is the most reliable indicator." Under Pain assessment and Management: "Pain assessments include a thorough pain assessment performed and documented on admission, pain assessment is to be completed at least each shift, include the patients pain goal, use the appropriate pain scale individulized to meet the patients needs, shall be completed with any change in paitents clinical status, completed after any invasive procedures, and included at the time of Handoff with a change in Caregiver. Pain reassessment is to be documented within 60 minutes of pharmacological interventions." Review of the pain scale revealed the pain is assessed on a scale from zero to 10 with zero being no pain and 10 being the worst possible pain.

1. Review of the medical record revealed Patient #2 arrived in the emergency department (ED) on 09/10/18 at 11:12 AM with abdominal pain since 4:00 AM on 09/10/18. The findings resulted in a five millimeter proximal left urethral stone( stone stuck in tube that carries urine from the kidneys to the bladder) causing moderate hydronephrosis (condition described as excess fluid in the kidney due to back up of urine). The patient was admitted to the hospital on 09/10/18 at 6:38 PM for pain control of the left flank area until a stent could be placed.

Review of the medication administration record (MAR) and the patient's flow sheet revealed on 09/10/18 at 11:52 AM the patient receive Fentanyl 75 micrograms (mcg) at 11:52 AM intravenous (IV). The patient rated his/her pain a 10 out of 10. Two Percocet dosage for 5/325 milligrams was given on 09/10/18 at 2:24 PM and the patient was not reassessed until 3:57 PM. The patient's pain was a six out of 10. The patient's pain goal was not documented on the pain assessment form and the patient did not receive any more pain medication until 5:42 PM at which time the patient rated his/her pain a nine out of 10. Dilaudid one mg IV was given and there was no documented evidence the patients pain level was reassessed within one hour. At 8:06 PM the patient rated his/her pain a six and there was no documented evidence any pain medication was given. On 09/11/18 at 5:44 PM the patient's pain level to the left flank area was an eight and the patient received Toradol 30 mg IV at 5:44 PM. There was no documented evidence the patient was reassessed within one hour.

Interview with Staff A on 01/24/19 at 10:15 AM revealed the policy is to follow up after pain medicine is given within the hour. There was no documented evidence in the medical record that this was done.

2. Review of the medical record for Patient #3 revealed the patient arrived in the ED on 02/24/18 9:51 PM for complaints of a rash on his/her bilateral hands with a redline from the left hand up to the bicep, and a rash on his/her trunk/legs and had tachycardia. The patient's diagnosis included cellulitis (bacterial infection involving the inner layers of the skin).

On 02/24/18 at 9:51 PM the patient rated his/her pain level a seven. The pain assessment did not include the patients goal for pain. The patient had orders for Tylenol. There was no pain medication given and there was no reassessment of the patient's pain. The patient was discharged from the hospital on 02/26/18 at 12:19 PM.

3. Review of the medical record of Patient #4 revealed the patient presented to the ED on 09/04/18 at 6:59 PM with complaints of confusion and worsening shortness of breath for 2 days. The patient was found to have severe hyponatremia (a condition that occurs when the level of sodium in the blood is too low), was intubated, and admitted to Cardiovascular Intensive Care Unit (CVICU). The patient's condition improved and he/she was transferred to 5 West, an adult inpatient unit, on 09/14/18 at 8:24 PM.

The pain assessment on 9/14/18 at 9:25 PM revealed the patient's rated pain was a 9 on a 0-10 scale. It was further noted that the patient's stated pain goal was a 4 on a 0-10 scale. The pain assessment on 9/15/18 at 10:21 AM revealed the patient rated pain a 6 on a 0-10 scale. According to the MAR the patient was medicated with Acetaminophen 1000 mg orally at 10:22 AM. The medical record lacked documentation the patient's pain was re-assessed until 4:00 PM, more than 5 hours later. The patient rated his/her pain an 8 at this time. At 10:11 PM on 9/15/18 the patient was noted to have acute rib cage pain, rating it a 9 on a 0-10 scale. The patient was again medicated with Acetaminophen 1000 mg however, the medical record lacked documentation the patient's pain wasn't re-assessed until 4:55 AM on 4/16/18. Patient #4's pain was again rated a 9 on a 0-10 scale and the patient was medicated with Acetaminophen 1000 mg at this time. Review of the pain flowsheet revealed the patient's pain wasn't re-assessed for more than 6 hours, at 11:01 AM. The patient rated his/her pain a 7 on a 0-10 scale at this time. The MAR indicated the patient was medicated with Acetaminophen 1000 mg at 11:01 AM. Review of the pain flowsheet revealed that the patient's pain wasn't reassessed until 4:46 PM where it remained a 7 on a 0-10 scale. The medical record lacked documentation a physician was notified of the patient's complaints of pain.

4. Review of the medical record for Patient #5 revealed the patient arrived in the ED on 12/08/18 at 10:23 PM. The chief complaint was urinary frequency with hematuria (red blood cells in the urine). The patient had a Trans-Urethral Resection of the Prostate (TURP) (surgery to remove tissue using instrument inserted through the urethra) four and a half weeks ago and was having hematuria. The patient last urinated around 5:00 PM today. The patient was admitted to the hospital on 12/09/18 at 11:56 AM for continuous bladder irrigation. The diagnoses included benign prostatic hypertrophy (enlargement of the prostate gland) with obstruction of the lower urinary tract.

Review of the patient's pain assessment form dated 12/08/18 did not include a pain goal for the patient. On 12/08/18 at 10:45 PM the patient rated his/her pain a 10 out of 10. The patient was medicated, but there was no one hour follow up assessment for the patient's pain. On 12/09/18 at midnight, the patient's pain level was a three; at 2:20 AM the pain level was a 10 out of 10. Two mg of Morphine IV was given, however, no reassessment for the effectiveness. At 4:40 AM the patient's pain level was a 10. Two mg Morphine IV was given. The reassessment at 5:10 AM revealed the pain was still a 10 out of 10 and one mg of Dilaudid was given at 5:10 AM. The pain reassessment at 5:40 AM revealed the pain level was a six and no pain medication was given.

5. Review of the medical record for Patient #6 revealed the patient arrived to the ED at 2:45 PM on 12/10/18. The patient was admitted to the hospital on 12/10/18. The chief complaint was loss of consciousness at the chemo infusion center while receiving chemotherapy. On 12/11/18 at 4:30 PM the patient complained of a headache and rated the pain an eight out of ten. Norco one tablet 5/325 mg was given. The patient's pain was not reassessed until four hours later at which time it was a zero. On 12/13/18 at 9:07 AM the patient headache was an eight out of 10 and one tablet Norco 5/325 mg was given; 12/14/18 at 12:14 PM the patients headache was an eight out of 10 and was given Norco; 12/14/18 at 8:26 PM Norco was given for headache and the pain was rated an eight; 12/15 at 12:31 PM one tab Norco was given for head pain of an eight; and on 12/15/18 at 10:05 PM Norco was given for head pain of a six. The patients pain for the above dates and times was not reassessed within one hour and the patient did not have a pain goal assessment completed on admission. The patient was discharged on 12/19/18.

6. Review of the medical record of Patient #8 revealed the patient presented to the Emergency Department on 10/31/18 at 7:20 AM with complaints of shortness of breath and worsening weakness. The patient was admitted to the Intensive Care Unit with a diagnosis of pneumonia. The patient was treated with antibiotics and breathing treatments and on 11/01/18 he/she was transferred to 4 West. The pain assessment for Patient #8 revealed the patient's pain was rated a 5 on a 0-10 scale on 11/01/18 at 8:51 PM. The MAR revealed the patient was medicated with Hydrocodone-Acetaminophen (Norco/pain medication) 5-325 mg at this time. The patient's pain wasn't re-assessed to determine its efficacy until 8:36 AM on 11/02/18. The patient's pain was rated a 9 at this time. The patient's pain was rated a 9 on a 0-10 scale on 11/06/18 at 10:36 PM. The patient was medicated with Norco at this time, however, the medical record lacked documentation the patient's pain was reassessed until 9:37 AM on 11/07/18, more than 10 hours later.

7. Review of the medical record of Patient #10 revealed the patient presented to the ED on 01/18/19 at 10:24 AM with shortness of breath since the day before. The patient was admitted and transferred to 4 West. The physician's H&P stated the patient was severely autistic (complex neurobehavioral condition) and nonverbal. Although the medical record lacked documentation on how the pain was assessed, given the patient's nonverbal status, the patient's pain was assessed at 1:30 AM on 1/19/19 and noted to be a 0 on a 0-10 scale. The medical record lacked documentation a pain assessment was conducted for more than 24 hours, at 9:00 PM on 1/20/19.

8. Patient #11 presented to the Emergency Department (ED) on 01/20/19 at 3:57 PM with complaints of severe abdominal pain, nausea, and vomiting for 3 months. The patient was medicated with Morphine (narcotic used to treat pain) 2 mg IV push at 7:52 PM for pain rated an 8 on a 0-10 scale and transferred to 4 West at 8:32 PM. The medical record lacked documentation that a pain assessment was included in the report given from ED staff to 4 West staff. A nursing note on admission to 4 West nurse stated: "Patient arrived via stretcher and ambulated to bathroom. Patient complained of pain in right lower abdomen radiating towards shoulder and back." Despite the patient's initial complaints of pain, a pain assessment was not completed until 12:15 AM on 01/21/19. The patient rated his/her pain a 10 on a scale of 0-10. The medical record lacked documentation the pain assessment included a pain goal or what is considered tolerable. The next pain assessment wasn't noted until 9:12 AM, more than 8 hours later. The patient again, reported his/her pain as severe, rating it a 9 on a 0-10 scale. The patient was medicated with Acetaminophen 1000 mg orally. According to the MAR, the patient was medicated with Acetaminophen 1000 mg at 8:44 PM. The patient rated his/her pain a 4 on a 0-10 scale at this time. The medical record lacked documentation the pain was not reassessed until 8:28 AM on 01/22/19, more than 11 hours after being medicated. The pain was rated a 10 on a 0-10 scale at this time. The pain assessment on 01/23/19 at 8:22 AM revealed the patient rated his/her pain a 10 on a 0-10 scale. The MAR noted the patient was medicated with Morphine 2 mg IV push. Documentation of the pain reassessment wasn't noted for more than 6 hours, at 2:49 PM. The patient rated his/her pain a 7 on a 0-10 scale.

Staff A, Director of Quality, was interviewed on 1/23/19 at 5:45 PM. Staff A reported pain assessments should be completed each 12 hour shift. It was confirmed the medical record lacked documentation the ED pain assessment was reported to 4 West staff at the time of the patient Handoff. It was also confirmed that the medical record lacked documentation a pain goal was ever assessed. The findings above where the pain was not reassessed within 60 minutes were also confirmed.

All of these findings were confirmed with the administrative staff prior to the exit conference on 01/24/19.