HospitalInspections.org

Based on policy review, document review, medical record review and interview, the hospital's Director of Nursing (DON) failed to assume responsibility for the hospitals nursing service. The DON's lack of leadership resulted in the first dose of inpatient home medications being scheduled without accurate information, medication doses being missed, the effectiveness of interventions for pain not being assessed and failure of the nursing staff to adhere to facility policies.

The findings included:

1. The Director of Nursing (DON) failed to assume responsibility for patient care provided by the hospital's nursing service by failing to provide supervision and oversight for home medication reconciliation, pain management, and for assessments and reassessments for 5 of 5 (Patient #1, 2, 3, 4 and 5) sampled patients.
Refer to A 386

2. The Director of Nursing (DON) failed to assume responsibility for supervision and oversight for nursing staff adherence to facility policies, monitoring of patients who received medications and for ensuring medications were administered according to physicians orders for 5 of 5 (Patient #1, 2, 3, 4 and 5) sampled patients.

Refer to A 405

Based on hospital policy review, document review, medical record review and interview, the Director of Nursing (DON) failed to assume responsibility for patient care provided by the hospital's nursing service by failing to provide supervision and oversight for home medication reconciliation, pain management, and for assessments and reassessments for 5 of 5 (Patient #1, 2, 3, 4 and 5) sampled patients.

The findings included:
1. Review of the hospital's "DIRECTOR OF NURSING/JOB DESCRIPTION" revealed, "...JOB SUMMARY... The Director of Nursing is responsible for the quality of nursing care given to patients at [named hospital]. The Director of Nursing plans, guides, teaches, observes, encourages, corrects, commends, and evaluates continuously the nursing care delivered by the employees of the Nursing Department..."

2. Review of the hospital's "JOB DESCRIPTION" for the Charge Nurse revealed, "...ESSENTIAL FUNCTIONS...Administers and documents medications as ordered and observes and documents patient reactions...Observes, records and reports to supervisor or physician patient's conditions and reactions to drugs, treatments and significant incidents..."

3. Review of the hospital's "JOB DESCRIPTION" for the Floor Nurse revealed, "...ESSENTIAL FUNCTIONS...Carries out medical and nursing treatment in a timely and accurate manner. Documents interventions and outcomes in a timely manner...Follows procedure for medication administration ..."

4. Review of the hospital's "Medication Reconciliation" policy revealed, "...Reconciliation of patient's home medications will be completed on every patient presenting for medical treatment in the Emergency Department [ED]... PROCEDURE... The licensed nurse will ask the presenting patient for a list of all home medications... Nurse will also review and document last dose taken/given..."

5. Review of the hospital's "PAIN MANAGEMENT" policy revealed, "...This policy provides guidelines to caregivers in how to assess, treat, and assist in managing a patient's pain...[named hospital] uses a self-rating scale 0-10 to evaluate pain. 0 indicates no pain, 10 indicates worst pain imaginable...Pain relief is the alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient and is demonstrated by a decrease in the patient's pain scale rating... PROCEDURE: PAIN MANAGEMENT - ALL PATIENTS...Assess for presence of pain for all patients...On initial assessment...At regular intervals, with a minimum of each shift and PRN [as needed]...With unrelieved pain...Re-assess pain intensity after each pain management intervention (pharmacological and non-pharmacological) once a sufficient time has elapsed for the treatment to reach peak effect (within 2 hours of intervention - general guidelines: 30 minutes for IV [intravenous], 60 minutes for PO [by mouth]/IM [intramuscular], and 15-60 minutes for non-pharmacological)...Principles of Intervention/Patient Education...The physician should be notified of pain that remains at a 6 or greater or higher than the patient's comfort level..."

6. Medical record review for Patient #3 revealed the patient arrived at the hospital via ambulance and was triaged in the Emergency Department (ED) on 11/28/15 at 7:10 AM for complaints of shortness of breath, cough, congestion and wheezing. At 9:00 AM, the patient was admitted to the hospital and transferred to the medical floor with a principal diagnosis of Pneumonia. The History & physical documented, "Positive expiratory wheezes." The physician's orders dated 11/28/15 documented, "...Resume all home meds..." Home meds noted by the RN on 11/28/15 at 10:45 AM included: Ranitidine 150 mg PO BID, Quinapril 20 mg PO daily, Folic Acid 1 mg PO TID, Montelukast 10 mg PO daily, Cetirizine 10 mg PO daily, Sertraline 50 mg PO daily, Potassium Chloride (KCl) 20 mEq PO daily, Metformin 500 mg PO BID, Clonazepam 0.5 mg PO at bedtime and Brovana 15 micrograms (mcg) inhaled neb (nebulizer) treatment BID for 15 minutes after Pulmocort. A physician's order dated 11/28/15 documented, "...Pulmocort aerosol [illegible] BID..."

Review of the INITIAL INTERVIEW and Medication Record revealed nursing staff failed to identify and document when Patient #3 had taken the last dose of home medications in order to ensure the first dosage of home medications as a hospital patient could be scheduled with accuracy. The record revealed Patient #3 did not receive the AM dose of home medications as an inpatient on 11/28/15.

Review of the Patient progress notes dated 11/28/15 at 4:04 PM, revealed a blood pressure of 182/102 while lying. There was no documentation that nursing administered Patient #3's daily dose of Quinapril 20 mg PO. A physician's order dated 11/28/15 at 4:30 PM revealed, "...Nitropaste ½ inch topical chest wall...after Norco 7.5 mg... ". There was no documentation that the Nitropaste was administered.

Review of Patient #3's "PATIENT PROGRESS NOTES" dated 11/29/15 revealed no pain assessment for the day shift was documented by nursing. At 2:47 PM on 11/29/15 the nurse documented the patient received Demerol 25 mg and Phenergan 12.5 mg. There was no pain assessment prior to administration of the pain medication or after the administration.
The Medication Record and Patient Progress Notes documented the following pain medications administered with no pain assessment conducted prior to medication administration and no pain reassessment after medication administration: Norco 10 MG PO on 11/28/15 at 7:40 AM (in Emergency Department); Norco 7.5 MG/325 MG PO on 11/28/15 at 4:50 PM; Gastrointestinal (GI) Cocktail 30 milliliters (ml) for epigastric pain on 11/28/15 at 2:56 PM, and on 11/29/15 at 5:16 AM and at 2:48 PM; and Demerol 25 MG IV on 11/29/15 at 2:47 PM.
The Medication Record and Patient Progress Notes documented the following pain medications administered with no pain reassessment conducted after medication administration: Oxycodone 5 MG/325 MG (acetaminophen) on 11/28/15 at 9:09 PM.

Review of the Nursing Assessment at 12:06 AM on 11/29/15 revealed the patient was wheezing. Review of the Medication Record revealed Patient #3 received Atrovent/Albuterol (Duoneb) on 11/28/15 at 9:09 PM and that the scheduled dose for 11/29/15 at 2:18 AM was omitted with the word "Sleeping" documented. The record documented a dose was given at 5:16 AM
Patient progress notes dated 11/29/15 documented, "...08:24 [8:24 AM] ...PULMICORT [BUDESONIDE] INH [inhalation] 0.5MG/2ML...Omitted DISCONTINUED..." There was no physician's order to discontinue Patient #3's Pulmicort and no documentation that nursing staff administered the AM dose of Patient #3's Pulmicort.

The Patient progress notes dated 11/29/15 documented, "...Pt daughter very irritated ...she [daughter] stated 'she [Patient #3] hasn't had a breathing treatment. she is smothering. yall [you all] aint doing anything for her here. im [I'm] taking her somewhere else..."

The patient was transferred to another hospital at 3:20 PM and a pain reassessment was not documented prior to transfer.

During an interview in the conference room on 1/25/16 at 1:45 PM, Patient #3's daughter stated her husband received a call from one of the nurses to inform him that Patient #3's blood pressure had shot up. Patient #3's daughter stated she came to the hospital, and her mother told her she had not received any of her home medications (including her blood pressure medication). Patient #3's daughter stated when she entered her mother's room on Sunday morning (11/29/15), her mother was in tears. Patient #3's daughter stated her mother told her she had not received her breathing treatment that morning and was smothering. Patient #3's daughter stated she told the nurses about her mother and then went to the ED to see if Physician #3 would come and check on her.

7. Medical record review for Patient #2 revealed the patient presented to the ED on 1/21/16 at 6:20 PM. He was admitted as an inpatient at 9:20 PM with diagnoses of Abdominal Pain, Upper Gastrointestinal Bleed, Anemia, and Hypotension. The physician's orders dated 1/21/16 for Patient #2 documented, "...Resume all home meds..." Home meds noted by the Licensed Practical Nurse (LPN) at 6:18 PM on 1/21/16 included: Buspar 15 mg PO 4 times a day (QID), Norco 7.5/325 mg PO PRN 3 times a day (TID) pain, Peractin 1 mg PO at bedtime (HS) and Prevacid 30 mg PO BID at 6:00 AM and 4:00 PM.
Nursing failed to identify and document when Patient #2 had taken the last dose of home medications so that scheduling if home medications could be acheived with accuracy.
The ED Pain Assessment and Management Flow sheet revealed RN #4 documented Patient #2 arrived in the ED at 6:35 PM with chronic burning abdominal pain of "7". On 1/21/16 at 7:15 PM, RN #4 documented the patient's pain scale as a "6" but did not document the location or the description of the pain. The pain assessment sheet was not timed or dated. There was no documentation the patient had received any pain medication.
The ED On-Going Assessment sheet dated 1/21/16 at 9:20 PM revealed RN #4 documented Patient #2 had abdominal pain 6/10 [6 out of 10] and complained of back pain. There was no description of the abdominal pain and no assessment of the back pain.
Review of the Patient progress notes (nurses notes) dated 1/21/16 at 9:20 PM revealed upon arrival to the medical floor RN #3 documented, "...pain scale "0...", Under the title Notes: "has been to the desk asking doctor for more pain meds [medication]...will continue to monitor..." There was no documentation the patient's pain had been assessed to include: pain scale, location of pain, character of pain, pattern or any interventions done.

Review of the Medication Record revealed Patient #2 received Norco 7.5 mg/325 mg on 1/21/16 at 10:07 PM. The medication was signed as being given by LPN #1.
There was no documentation in the Patient progress notes a pain assessment was conducted to include pain scale, location of pain, character of pain, pattern and any interventions. There was no documentation the patient's pain level was reassessed after pain medication was given.
The Patient progress notes dated 1/21/16 at 10:50 PM revealed Patient #2's wife was at the nurses desk asking for more pain medication for patient. There was no documentation a pain assessment was conducted or that pain medication was given.

The Patient progress notes dated 1/22/16 at 12:02 AM revealed LPN #2 documented the patient had chronic, dull aching back pain with a pain scale of "6", Intervention: Toradol 30 mg given IV.
The Patient progress notes dated 1/22/16 at 12:36 AM revealed LPN #2 documented the patient had continued abdominal pain. There was no documentation a pain reassessment was conducted after the pain medication was administered or the physician had been made aware of patient's continued pain.
The Patient progress notes dated 1/22/16 at 5:26 AM revealed RN #5 documented, "...patient resting throughout the night with no complaints...agree with previous nursing shift assessment..."

The Patient progress notes dated 1/22/16 at 8:05 AM revealed LPN #3 documented under Pain: patient had chronic, dull aching "sore" abdomen pain with a pain scale of "5", Intervention: PRN medication. Under the title notes LPN #3 documented, "...no distress noted. Pt [patient] complaining of back and abdominal pain..." Review of the Medication Record revealed Patient #2 received Norco 7.5 mg/325 mg PO on 1/22/16 at 8:07 AM. The Norco was signed as being given by LPN #3. There was no documentation the patient was reassessed after pain medication was given.

Review of the Medication Record revealed Patient #2 received Demerol 25 mg IV on 1/22/16 at 8:50 AM. The Demerol was signed as given by LPN #3 at 8:50 AM. There was no documentation in the Patient progress notes of a pain assessment or reason the Demerol was given. There was no documentation the patient was reassessed after pain medication was given.
The Patient progress notes dated 1/22/16 at 12:39 PM revealed the Assistant Director of Nursing documented, "...I have reviewed and agree with LPN'S [Licensed Practical Nurse] pt. physical assessment..."

The Patient progress notes dated 1/22/16 at 1:45 PM revealed LPN #3 documented, "...pt complaining of chronic back and abdominal pain. Notified charge nurse because not time for PRN medication..." There was no documentation in the Patient progress notes a pain assessment was done to include pain scale, character of pain, pattern and any interventions.

The Medication Record revealed Patient #2 received Norco 7.5 mg/325 mg PO on 1/22/16 at 1:55 PM. The Norco was signed as given by LPN #3. There was no documentation the patient was reassessed after the pain medication was given.

The Medication Record revealed Patient #2 received Demerol 25 mg IM on 1/22/16 at 2:44 PM. The Demerol was signed as given by LPN #3 at 2:44 PM. There was no documentation in the Patient progress notes a pain assessment was conducted before the Demerol was given. There was no documentation the patient was reassessed after pain medication was given.

Review of the Medication Record revealed Patient #2 received Percocet 5/325 mg on 1/22/16 at 6:25 PM. The Percocet was signed as given by LPN #3 at 6:25 PM. There was no documentation in the Patient progress notes a pain assessment was conducted before the Percocet was given. There was no documentation the patient was reassessed after pain medication was given.

The Patient progress notes dated 1/22/16 at 10:00 PM revealed LPN #4 documented Patient #2 had constant aching abdomen pain with a pain scale of "9". Interventions: PRN medications, Repositioning and Reassurance.
The Medication Record revealed Patient #2 received Demerol 25 mg IM on 1/22/16 at 10:28 PM. The Demerol was signed out as being given by LPN #4. There was no documentation the patient's pain had been assessed after medication given to include: pain scale, location of pain, character of pain, or pattern.

Review of the Medication Record revealed Patient #2 received Norco 7.5 mg/325 mg PO on 1/22/16 at 10:54 PM. The Norco was signed out as being given by LPN #4. There was no documentation the patient's pain had been assessed before or after pain medication given to include: pain scale, location of pain, character of pain, or pattern.

Review of the Medication Record revealed Patient #2 received Percocet 5 mg/325 mg PO on 1/23/16 at 12:02 AM. The Percocet was signed as being given by LPN #4. There was no documentation the patient's pain had been assessed before or after pain medication given to include: pain scale, location of pain, character of pain, or pattern.

The Patient progress notes dated 1/23/16 at 2:00 AM revealed LPN #4 documented, "...PRN's administered for c/o constant pain/anxiety, ineffective at this time..." There was no documentation the physician had been notified of Patient #2's constant unrelieved pain.

Review of the Medication Record revealed Patient #2 received Demerol 25 mg IM and Phenergan 25 mg IM on 1/23/16 at 3:22 AM. The Demerol and Phenergan was signed out as being given by LPN #4. There was no documentation the patient's pain had been assessed before or after the pain medication was given to include: pain scale, location of pain, character of pain, or pattern.

The Medication Record revealed Patient #2 received Norco 7.5 mg/325 mg PO on 1/23/16 at 3:41 AM. The Norco was signed out as being given by LPN #4. There was no documentation the patient's pain had been assessed before or after pain medication given to include: pain scale, location of pain, character of pain, or pattern.

The Medication Record revealed Patient #2 received Percocet 5 mg/325 mg PO on 1/23/16 at 6:01 AM. The Percocet was signed as being given by LPN #4. There was no documentation the patient's pain had been assessed before or after pain medication given to include: pain scale, location of pain, character of pain, or pattern.

The Patient progress notes dated 1/23/16 at 8:05 AM revealed Patient #2's Blood Pressure (BP) was documented by LPN #3 as 164/112. There is no documentation the BP was reassessed for accuracy.

Review of the Medication Record dated 1/23/16 at 9:31 AM, revealed Patient #2 received Nitro-Bid Ointment. The Nitro-Bid was signed out by LPN #5. There was no documentation the BP was reassessed after the ointment was applied.

The Medication Record dated 1/23/16 revealed Patient #2 received Norco 7.5 mg/325 mg PO at 11:28 AM, Demerol 25 mg IM at 9:27 AM and 1:44 PM, Percocet 5/325 mg PO at 12:56 PM. There was no documentation the patient's pain had been assessed before or after the pain medication given to include: pain scale, location of pain, character of pain, or pattern. There was no documentation a pain assessment had been conducted on 1/23/16.

Patient #2 was transferred on 1/23/16 at 2:20 PM via ambulance to another hospital for a higher level of care with a diagnosis of Upper Gastrointestinal Bleed.

8. Medical record review for Patient #1 revealed a direct admission to the hospital on 10/8/15 at 3:30 PM with a principal diagnosis of Gastroenteritis. The physician's orders dated 10/8/15 at 4:00 PM documented, "...Continue home meds [medications] - hold Lasix..." Home meds noted by the Registered Nurse (RN) on 10/8/15 at 4:45 PM included: Lexapro 20 milligrams (mg) daily, Vitamin D 50,000 units by mouth (PO) weekly, Protonix 40 mg PO daily - Substitute Prevacid 30 mg PO daily, Lasix 40 mg 1/2 to 1 tablet daily HOLD, Klor Con 10 milliequivalents (mEq) PO daily, Hydrocodone/Acet 10/325 mg PO every 6 hours as needed (PRN) pain, Xanax 2 mg PO twice a day (BID) PRN anxiety.
Nursing failed to identify and document when Patient #1 had taken the last dose of home medications to ensure home medications could be scheduled with accuracy.

The Medication Record and Patient Progress Notes documented the following pain medications were administered with no pain assessment documented prior to the medication administration and no pain reassessment was documented after the medication administration: Norco 10 milligrams (hydrocodone MG/325 MG acetaminophen) PO (by mouth) on 10/8/15 at 8:43 PM, on 10/9/15 at 4:13 AM and 9:50 AM, on 10/10/15 at 3:50 AM and at 4:50 PM, on 11/11/15 at 3:36 PM and at 11:39 PM, and on 10/12/15 at 6:50 AM and at 4:28 AM; Toradol 30 MG IV on 10/10/15 at 8:56 PM, on 10/11/15 at 9:10 AM, and on 10/12/15 at 11:05 AM; and Morphine Sulfate 4 MG IV on 10/12/15 at 8:55 PM.
The Medication Record and Patient Progress Notes documented the following pain medication was administered with no pain assessment conducted prior to medication administration: Norco 10 MG/325 MG PO on 10/8/15 at 5:15 PM.
The Medication Record and Patient Progress Notes documented the following pain medications administered with no pain reassessment conducted after medication administration: Norco 10 MG/325 MG PO on 10/9/15 at 8:45 PM and Toradol 30 MG IV on 10/11/15 at 8:16 PM.

The Medication Record and Patient Progress Notes documented Norco 10 MG/325 MG PO was administered on 10/10/15 at 8:24 AM. A pain assessment was conducted at 9:45 AM (1 hour 21 minutes after medication administration) as a "6" on the pain scale. The pain assessment was not conducted per policy ("...60 minutes for PO..."), and there was no documentation the physician was notified of the patient's pain that remained at a 6.

9. Medical record review for Patient #4 revealed an admission date of 1/23/16 with diagnoses of Gastroenteritis with Nausea, Vomiting, Abdominal Pain, Leukocytosis and Rule Out Sepsis. Physician's orders dated 1/23/16 documented, "... Resume all home meds..." Home medications noted by the RN on 1/23/16 at 4:00 PM included: Pepcid 20 mg PO daily and Reglan 10 mg PO daily.
Nursing failed to identify and document when Patient #4 had taken the last dose of home medications to ensure home medications could be scheduled with accuracy.

The Medication Record and Patient Progress Notes documented the following pain medications administered with no pain assessment conducted prior to medication administration and no pain reassessment after medication administration: Demerol 25 MG IM on 1/23/16 at 12:39 PM (in Emergency Department) and at 5:16 PM.
The Medication Record and Patient Progress Notes documented the following pain medication administered with no pain assessment conducted prior to medication administration: Demerol 50 MG IV on 1/23/16 at 2:05 PM (in Emergency Department).
The Medication Record and Patient Progress Notes documented the following pain medication administered with no pain reassessment conducted after medication administration: Demerol 25 MG IV on 1/23/16 at 11:10 AM.

10. Medical record review for Patient #5 revealed the patient arrived at the ED at 10:50 PM on 1/24/16 with complaint of shortness of breath, coughing and congestion The patient was admitted as an inpatient with diagnoses of Right Middle Lobe Pneumonia, Congestive Heart Failure, Hypoxemia and Anemia. The physician's orders dated 1/24/16 for Patient #5 revealed, " ...Resume all home meds..." Home meds noted by the LPN on PM included: Allopurinol 100 mg PO daily, Fluoxetine 20 mg PO daily, Gabapentin 300 mg PO TID, Metoprolol Tartrate 50 mg PO BID, Nifedical XL 30 mg PO daily, Omeprazole 40 mg PO daily, Ranitidine 300 mg PO HS, Xifaxam 550 mg PO BID, Buspirone HCl 15 mg PO BID, Hydralazine HCl 100 mg PO TID, and Oxycodone HCl 5 mg PO BID.
Nursing failed to identify and document when Patient #5 had taken the last dose of home medications to ensure home medications could be scheduled with accuracy.

Review of the Initial Physical Assessment dated 1/25/16 at 1:30 AM revealed Nurse #10 documented, "... Pain Scale: "8", Character of Pain: Burning, Pattern: Acute, Intervention: Reassurance...". There was no documentation the patient had received any pain medication for pain scale of "8". There was no documentation the patient had been reassessed for pain.

11. During an interview in the conference room on 1/25/16 at 1:00 PM, RN #1 stated the nurses were supposed to assess every patient's pain at least once each shift and document the assessment in the computer on the flowsheet. RN #1 stated the nurses worked 8 hour shifts during the week (Monday through Friday) and 12 hour shifts during the weekend (Saturday and Sunday).

During an interview on 1/27/16 at 8:30 AM, RN #1 verified the pain assessments were not being conducted according to hospital policy. RN #1 stated, "...pain meds [medications] should be reassessed within 1 hour depending on the type of pain. If it is IV, should be short while it kicks in, PO 45 minutes to 60 minutes, IM somewhere in between, usually 15 minutes for IV..." RN #1 verified the pain assessments and medications should be charted in the nursing notes. RN #1 stated she "...did not always review the LPN assessment..." RN #1 verified that Patient #2's pain medication was not charted and BP was not reassessed on 1/23/16 and stated, "...I'm seeing they were not charted...nurses have been in-serviced in the past. We have lot[s] of new nurses. Get [nurses] in-serviced in orientation, I think..." When asked about the pain documentation for Patient #2 on 1/21/6 at 9:20 PM, and 1/23/16 RN #1 stated, "...I guess the nurse on the floor did not assess the pain..."

12. During an interview in the conference room on 1/26/15 at 1:50 PM, when asked how the nurses assessed when the last dose of a home medication was taken by a patient upon admission, the DON stated, " ...not sure how they [nurses] do that now ..." The DON stated she was unaware of how the nurses identified when the last dose of a home medication was taken, because she spent most of her time in her office. When asked if the nurses ask the patient or family when the last dose of a home medication was taken, the DON stated, " ...we [nursing] have not been doing that ..."
During an interview in the conference room on 1/26/16 at 2:30 PM, when asked what time frame should nurses give a 1 time order the DON stated, "...I expect a 1 time order to be given within 30 minutes...". When asked the protocol for assessing medications the DON stated, "...pain should be assessed upon admission and with each assessment. The nurse should document the patients complaint of pain, ask the pain scale 1-10, the location and pattern of pain, document this and then check the medication record for pain meds, if none ordered then they should call the physician. If ordered they should give the med and then go back and check the patient and see if the med helped ask the pain scale and document results...The time frame for reassessing, the policy says IV 30 minutes, PO 60 minutes, I can't remember the exact time for the other interventions...". When asked what should occur if no improvement in the patients pain, the DON stated the nurses should check the Medication Record for other pain medications, if the patient does not have anything else then they [nurse] should call the physician for further orders or to come and evaluate the patient." When asked if nurses had been in-serviced regarding pain medications and assessments the DON stated, "...we have new nurses that may not have been in-serviced..."

13. During an interview in the conference room on 1/27/16 at 9:30 AM, the Quality Assurance Performance Improvement (QAPI) and Infection Control (IC) Coordinator stated the nurses were responsible for identifying and documenting the last dose of each home medication for a patient upon admission. She stated, " if they come in through the ED [emergency department], the ED nurse is supposed to do it [verify home medications and last dose taken]. If they don't , the floor nurses should. " The QAPI and IC Coordinator stated the DON was in charge of the education of the nurses which included identifying and documenting the last dose of a patient's home medications. The Quality Assurance Performance Improvement (QAPI) and Infection Control (IC) Coordinator stated the DON was in charge of the education of the nurses which included identifying and documenting the last dose of a patient's home medications.

14. During an interview at the nurses ' station on 1/27/16 at 11:25 AM, RN #2 stated "the nurses do not ask the patient or family when the last dose of their home medication was taken..."

Based on hospital policy review, document review, medical record review and interview, the Director of Nursing (DON) failed to assume responsibility for supervision and oversight for ensuring medications were administered according to physician's orders and for ensuring nursing staff adhered to hospital policy & procedure for monitoring the effectiveness of medication interventions for control of pain for 5 of 5 (Patient #1, 2, 3, 4 and 5) sampled patients.

The findings included:

1. Review of the hospital's "DIRECTOR OF NURSING/JOB DESCRIPTION" revealed, "...JOB SUMMARY... The Director of Nursing is responsible for the quality of nursing care given to patients at [named hospital]. The Director of Nursing plans, guides, teaches, observes, encourages, corrects, commends, and evaluates continuously the nursing care delivered by the employees of the Nursing Department..."

Review of the hospital's "JOB DESCRIPTION" for the Charge Nurse revealed, "...ESSENTIAL FUNCTIONS...Administers and documents medications as ordered and observes and documents patient reactions...Observes, records and reports to supervisor or physician patient's conditions and reactions to drugs, treatments and significant incidents..."

Review of the hospital's "JOB DESCRIPTION" for the Floor Nurse revealed, "...ESSENTIAL FUNCTIONS...Carries out medical and nursing treatment in a timely and accurate manner. Documents interventions and outcomes in a timely manner...Follows procedure for medication administration ..."

2. Review of the hospital's "PAIN MANAGEMENT" policy revealed, "...[named hospital] uses a self-rating scale 0-10 to evaluate pain. 0 indicates no pain, 10 indicates worst pain imaginable... PAIN MANAGEMENT - ALL PATIENTS...Assess for presence of pain for all patients... Re-assess pain intensity after each pain management intervention (pharmacological and non-pharmacological) once a sufficient time has elapsed for the treatment to reach peak effect (within 2 hours of intervention - general guidelines: 30 minutes for IV [intravenous], 60 minutes for PO [by mouth]/IM [intramuscular], and 15-60 minutes for non-pharmacological)... The physician should be notified of pain that remains at a 6 or greater or higher than the patient's comfort level..."

3. Medical record review for Patient #1 revealed an admission date of 10/8/15. The medical record documented the following pain medications were administered with no pain assessment documented after administration: Norco 10 milligrams (hydrocodone MG/325 MG acetaminophen) PO (by mouth) on 10/8/15 at 8:43 PM, on 10/9/15 at 4:13 AM, 9:50 AM and 8:45 PM, on 10/10/15 at 3:50 AM and at 4:50 PM, on 11/11/15 at 3:36 PM and at 11:39 PM, and on 10/12/15 at 6:50 AM and at 4:28 PM; Toradol 30 MG IV on 10/10/15 at 8:56 PM, on 10/11/15 at 9:10 AM and 8:16 PM and on 10/12/15 at 11:05 AM; and Morphine Sulfate 4 MG IV on 10/12/15 at 8:55 PM.

The Medication Record and Patient Progress Notes documented Norco 10 MG/325 MG PO was administered on 10/10/15 at 8:24 AM. A pain assessment was conducted at 9:45 AM (1 hour 21 minutes after medication administration) as a "6" on the pain scale. The pain assessment was not conducted per policy ("...60 minutes for PO..."), and there was no documentation the physician was notified of the patient's pain that remained at a scale of 6.

4. Medical record review for Patient #2 revealed an admission date of 1/21/16. The medical record documented the following pain medications were administered with no pain assessment documented after the medication administration:
Norco 7.5 mg/325 mg on 1/21/16 at 10:07 PM, Toradol 30 mg was given IV on 1/22/16 at 12:02 AM, Norco 7.5 mg/325 mg PO on 1/22/16 at 8:07 AM, Demerol 25 mg IV on 1/22/16 at 8:50 AM, Norco 7.5 mg/325 mg PO on 1/22/16 at 1:55 PM, Demerol 25 mg IM on 1/22/16 at 2:44 PM, Percocet 5/325 mg on 1/22/16 at 6:25 PM, Demerol 25 mg IM on 1/22/16 at 10:28 PM, Norco 7.5 mg/325 mg PO on 1/22/16 at 10:54 PM, Percocet 5 mg/325 mg PO on 1/23/16 at 12:02 AM, Demerol 25 mg IM and Phenergan 25 mg IM on 1/23/16 at 3:22 AM, Norco 7.5 mg/325 mg PO on 1/23/16 at 3:41 AM, Percocet 5 mg/325 mg PO on 1/23/16 at 6:01 AM, Norco 7.5 mg/325 mg PO at 11:28 AM, Demerol 25 mg IM at 9:27 AM and 1:44 PM, Percocet 5/325 mg PO at 12:56 PM.

Patient #2 was transferred on 1/23/16 at 2:20 PM via ambulance to another hospital for a higher level of care with a diagnosis of Upper Gastrointestinal Bleed.

5. Medical record review for Patient #3 revealed an admission date of 11/28/15. The medical record documented the following pain medications administered with no pain reassessment after medication administration: Norco 10 MG PO on 11/28/15 at 7:40 AM (in Emergency Department); Norco 7.5 MG/325 MG PO on 11/28/15 at 4:50 PM; Gastrointestinal (GI) Cocktail 30 milliliters (ml) for epigastric pain on 11/28/15 at 2:56 PM, Oxycodone 5 MG/325 MG (acetaminophen) on 11/28/15 at 9:09 PM, and on 11/29/15 at 5:16 AM and at 2:48 PM; and Demerol 25 MG IV on 11/29/15 at 2:47 PM.

Review of a physician's order dated 11/28/15 revealed, "...Pulmocort aerosol [illegible] BID..." The Patient progress notes dated 11/29/15 documented, "...08:24 [8:24 AM] ...PULMICORT [BUDESONIDE] INH [inhalation] 0.5MG/2ML...Omitted DISCONTINUED..." There was no physician's order to discontinue Patient #3's Pulmicort and no documentation that nursing staff administered the AM dose of Patient #3's Pulmicort.

Review of the Patient progress notes dated 11/28/15 at 4:04 PM, revealed a blood pressure of 182/102. There was no documentation that nursing administered Patient #3's daily dose of Quinapril 20 mg PO. A physician' s order dated 11/28/15 at 4:30 PM revealed, "...Nitropaste ½ inch topical chest wall...after Norco 7.5 mg... ". There was no documentation that the Nitropaste was administered.

During an interview in the conference room on 1/25/16 at 1:45 PM, Patient #3's daughter stated her husband received a call from one of the nurses to inform him that Patient #3's blood pressure had shot up. Patient #3's daughter stated she came to the hospital, and her mother told her she had not received any of her home medications (including her blood pressure medication).

6. Medical record review for Patient #4 revealed an admission date of 1/23/16. The medical record documented the following pain medications administered with no pain reassessment after administration: Demerol 25 MG IV on 1/23/16 at 11:10 AM. Demerol 25 MG IM on 1/23/16 at 12:39 PM and at 5:16 PM.

7. Medical record review for Patient #5 revealed an admission date of 1/24/16 with.
Review of the Initial Physical Assessment dated 1/25/16 at 1:30 AM revealed Nurse #10 documented, "... Pain Scale: "8". There was no documentation the patient had received any pain medication for a pain scale of 8. There was no documentation the patient had been reassessed for pain.

8. During an interview in the conference room on 1/26/16 at 2:30 PM, when asked what time frame should nurses give a 1 time order the DON stated, "...I expect a 1 time order to be given within 30 minutes...". When asked the protocol for assessing medications the DON stated, "... The nurse should document the patients complaint of pain, ask the pain scale 1-10, the location and pattern of pain, document this and then check the medication record for pain meds, if none ordered then they should call the physician. If ordered they should give the med and then go back and check the patient and see if the med helped ask the pain scale and document results..."

9. During an interview on 1/27/16 at 8:30 AM, RN #1 verified the pain assessments were not being conducted according to hospital policy. RN #1 stated, "...pain meds [medications] should be reassessed within 1 hour depending on the type of pain. If it is IV, should be short while it kicks in, PO 45 minutes to 60 minutes, IM somewhere in between, usually 15 minutes for IV..."

10. During an interview in the conference room on 1/27/16 at 9:30 AM, the Quality Assurance Performance Improvement (QAPI) and Infection Control (IC) Coordinator stated the DON was in charge of the education of the nurses.

Based on policy review, medical record review, and interview, the facility failed to ensure medical record entries were legible, complete, timed and accurate for 5 of 5 (Patient #1, 2, 3, 4, and 5) sampled patients.

The findings included:

1. Review of the hospital's "INFORMATION MANAGEMENT PLAN" policy revealed, "...maintains a medical record that is documented legibly and accurately and in a timely manner...the medical record contains sufficient information to identify the patient, support the diagnosis, justify the treatment and documents the results accurately... the physical examination report shall reflect a comprehensive current physical assessment...in the interest of accuracy, legibility and responsibility, medical record entries, when appropriate, are typed..."

2. Review of the hospital's "MEDICATION ADMINISTRATION" policy revealed, "...Dosage, frequency, route of administration, and times will be entered for all ordered medications..."

3. Medical record review for Patient #1 revealed an admission date of 10/8/15 with a principal diagnosis of Gastroenteritis. A physician's order dated 10/8/15 by Physician #2, a physician's order dated 10/10/15 by Physician #3, a physician' s order dated 10/10/15 by Nurse Practitioner #1 and a physician's order dated 10/12/15 by Nurse Practitioner #2 were not timed. Physician's progress notes dated 10/8/15, 10/9/15, 10/11/15 and 10/12/15 by Physician #2 were not timed. A physician's progress note dated 10/10/15 by Physician #5 was not timed.

4. Medical record review for Patient #2 revealed an admission date of 1/21/16 with diagnoses of Abdominal Pain, Upper Gastrointestinal Bleed, Anemia, and Hypotension.
Review of the Emergency Department Physical Exam record dated 1/21/6 revealed Physician #3 documented, "...nephrostomy catheter L [LEFT] side...". Patient #2 did not have a nephrostomy catheter.
Review of a physician's order dated 1/21/16 revealed an order for Norco written as 705 milligrams (mg) instead of 7.5 mg and signed by Physician #3. The physician's orders on 1/21/16 and 1/22/16 revealed there was no documentation of the time the orders were written by Physician #3.
Review of the physician progress notes dated 1/21/16 revealed the 3 pages of progress notes were signed by Physician #3 but not timed. The blood pressure measurement on page 2 was illegible.

The Patient progress notes dated 1/22/16 at 12:02 AM revealed LPN #2 documented the patient had chronic, dull aching back pain with a pain scale of "6", Intervention: Toradol 30 mg given IV.
The Patient progress notes dated 1/22/16 at 12:36 AM revealed LPN #2 documented the patient had continued abdominal pain. There was no documentation a pain reassessment was conducted after the pain medication was administered or the physician had been made aware of patient's continued pain.
The Patient progress notes dated 1/22/16 at 5:26 AM revealed RN #5 documented, "...patient resting throughout the night with no complaints...agree with previous nursing shift assessment..."

During an interview in the conference room on 1/27/16 at 8:30 AM, the Director of Nursing (DON) stated she did not recall Patient #2 having a nephrostomy catheter. The DON stated the facility did have a patient recently with a nephrostomy catheter. The Don was asked about the legibility of the orders and stated if the nurses could not read the orders they [the nurses] would telephone the physician for clarification. When the DON was shown the orders and the progress notes written by Physician #3 on 1/21/16 and 1/22/16 the DON verified she was unable to read some of the orders and the progress notes .

5. Medical record review for Patient #3 revealed an admission date of 11/28/15 with diagnoses of Pneumonia, Chronic Obstructive Pulmonary Disease, Diabetes, and Hypertension. A physician's order dated 11/28/15 and two physician's orders dated 11/29/15 by Physician #3 were not timed. The physician progress notes dated 11/28/15 and 11/29/15 by Physician #3 were not timed.
A physician's order dated 11/28/15 documented, "...Pulmocort aerosol [illegible] BID..."

6. Medical record review for Patient #4 revealed an admission date of 1/23/16 with diagnoses of Gastroenteritis with Nausea, Vomiting, Abdominal Pain, Leukocytosis and Rule Out Sepsis. A physician's order dated 1/23/16 and two separate physician's orders dated 1/24/16 by Physician #3 and a physician's order dated 1/25/16 by Nurse Practitioner #2 were not timed. Physician's progress notes dated 1/23/16 and 1/24/16 by Physician #3 and 1/25/16 were not timed.

7. Medical record review for Patient #5 revealed an admission date of 1/24/16 AT 1:00 AM with a diagnosis of Right Middle Lobe Pneumonia, Congestive Heart Failure, Hypoxemia and Anemia.
Review of the Physician orders dated 1/24/16 and signed by Physician #3 did not document the time the orders were written by the physician. There was no documentation for the route and time for Rocephin. The time and route for Rocephin was added in and did not have initials, time or date. The order for Zithromax was written for PO (oral) route. The Zithromax route was changed to IV by a slash marked through PO. The change was not timed or dated and had only initials beside it. The orders had not been signed as being received by nursing.