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Based on interviews, the review of medical record and other documents, it was determined the facility failed to ensure the implementation of nursing policies and procedures. Specifically, nursing staff failed to (1) confer with appropriate medical staff relative to management of patients with acute/chronic pain; (2) implement the facility's policy on pressure ulcer prevention and management to assure patient care needs are met. These findings were noted in 4 of 20 patient records reviewed.

Findings include:

1. Patient #1 is an 84 year-old male who was triaged in the Emergency Department on 8/17/14 at 6:13 PM with complaints of abdominal pain and constipation. Vital signs were as follows: Temperature 101.5 F, Pulse 102, and Blood Pressure 119/87. The patient rated his pain as level 7 on a scale of 1 -10.

In the ED, the patient was treated with antibiotics and Tylenol was given for elevated temperature of 101.5 degree Fahrenheit. The patient was admitted with diagnosis of infectious colitis/sepsis and possible urinary Tract Infection.

There was no evidence the patient's pain was managed until almost 17 hours after his initial presentation to the Emergency Department. The patient's pain was not reassessed and managed in the Emergency Department.

On admission of the patient to an inpatient unit on 8/18/14 at 04:09 AM, nursing assessment at 04:09 AM and 04:16 AM indicated the patient was still in severe pain rated at 7/10. There was no management of the patient's pain until a stat order was written on 8/18/14 at 11:30 AM for Morphine Sulfate, 2 milligram (mg) injection, to be given intramuscularly. Another order was written on 8/18/14 at 11:37 AM for Morphine 2 mg injection, to be given subcutaneously. The orders were implemented on 8/18/14 at 11:30 AM and 12:24 PM respectively. Reassessment of the patient on 8/18/14 at 1:24 PM, noted the patient's pain was relieved; pain level noted as 1/10.

The facility's policy statement regarding pain management indicates patients have the right to appropriate assessment and management of pain, and should be afforded appropriate and timely interventions, in an effort to manage, reduce, or relieve acute/chronic pain.

At interview with Staff #1 on 8/26/14 at 2:45 PM, she stated that nursing staff has the responsibility to conduct pain assessment and reassessment utilizing available pain rating scales. She stated patient's pain scale is reported immediately to the physician for appropriate evaluation and intervention.


Patient #2 is a 46-year-old male who was admitted to the facility on 8/3/14. The patient's status was post physical assault and found to have an open fracture of the tibia shaft. The patient underwent a left lower extremity open reduction and internal fixation for a comminuted grade 1 open tibial fracture.

The review of the patient's Pain Management Record on 8/27/14 noted that pain management was not timely provided to the patient. The record notes that the patient's pain score was 8/10 on 8/17/14 at 09:52 AM and was medicated with Percocet 2 tabs. There was no reassessment of the patient until about nine hours later at 7:00 PM on 8/17/14; at this time, the patient's pain score was 9/10.

On 8/18/14, at 1:30 PM, the patient was noted with severe pain rated 9/10 and was medicated with Morphine 10 mg injection. There was no reassessment of the patient until 11:44 PM; the assessment did not include a pain score, but notes that Tylenol 325 mg was given.

The facility's policy statement regarding pain management notes patients have the right to appropriate assessment and management of pain, and should be afforded appropriate and timely interventions, in an effort to manage, reduce, or relieve acute/chronic pain.

At interview with Staff #1 on 8/26/14 at 2:45 PM, she stated that nursing staff has the responsibility to conduct pain assessment and reassessment utilizing available pain rating scales. She stated patient's pain scale is reported immediately to the physician for appropriate evaluation and intervention.

Interview with Staff #2 on 8/27/14 at 1:10 PM, she stated patients are reassessed one hour after oral or subcutaneous analgesic is administered and thirty minutes after intravenous or intramuscular analgesics is administered.

2. The review of medical record for Patient #3 on 8/26/14 noted the patient was admitted on 7/9/14 with multiple pressure ulcers; a right hip, stage II, 3 centimeter (cm) X 2 centimeter (cm); left heel, DTI (Deep tissue injury), 5 cm X 4 cm; a left foot, DTI, 6 cm X 3 cm; right foot, 2 cm X 1 cm; sacral stage I, 9 cm X 7 cm X 4 cm; right heel, DTI, 4 cm X 3 cm. Physician orders were noted on 7/10/14 for Duoderm application to ulcers on right heel, left heel, left foot, and right foot. Also noted were dressing orders to the sacral and right hip ulcers.

Nursing staff failed to assure that weekly reassessment of patients with pressure ulcers includes description of ulcers in order to monitor the healing status of pressure ulcers.

Nursing progress notes for 7/23/14 at 08:15 AM, 7/30/14 at 03:26 AM, 8/6/14 at 10:47 AM, 8/13/14 at 6:04 PM did not provide information regarding the stage of ulcers, size, color, odor, and drainage, nor were photographs taken in accordance with the facility's policy for pressure ulcer prevention and management.

The facility's policy titled "Pressure Ulcers Prevention and Management" last revised May 2014 notes, Risk assessment are done on admission, transfer, identification of new pressure ulcer and every Wednesday. Photograph all pressure ulcers upon admission, transfer, and newly developed pressure ulcer with weekly reassessment. A complete reassessment of the pressure ulcer including documentation of wound dimensions (odor, increased drainage, necrosis), is done weekly every Wednesday and with any change in wound condition.

-Patient #4 was evaluated in the Emergency Department on 8/22/14 with chief complaint of fever and was admitted with the diagnosis of sepsis. The initial nursing assessment of the patient on 8/22/14 notes an unstageable sacral ulcer, 11 cm X 11 cm X 2 cm. There was no evidence of prompt referral and management of the patient's pressure ulcer. Physician order for treatment of the pressure was written on 8/25/14 at 01:19 AM; the third day of admission.

The policy on Pressure Ulcers prevention and Management notes that nursing staff will notify Provider of all stage II pressure ulcers and higher and Providers will assess and write orders for their management.

Interview with Staff #3 on 8/26/14, she stated that treatment orders for pressure ulcers should be obtained upon initial nursing assessment. In addition, the reassessment of pressure ulcer is done every Wednesday and nurses are expected to document the description of each ulcer in accordance with facility's policy.