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Based on medical record review and staff interview the facility failed to evaluate the pain medication effects for two of five patients whose medical records were reviewed. (Patient #'s 2 and 3). The facility failed to assess an intravenous infiltrate and clearly document the events during the restarting of an intravenous access. (Patient #4).

Findings included:

Review of the medical record for patient #3 on 1/19/11 revealed this patient had back surgery on 8/26/10. The nursing documentation for the administration of pain medication for the dates of 8/27/10 at 8:30 AM described the patient as complaining of sharp back pain with a rating of 7 out of 10 being the worst pain. Pain medication was given at 1:15 PM for patient complaints of pain with a rating of 9 of 10, and at 2:42 PM, 5:45 PM and 7:20 PM rated by the patient as 8 of 10. There was no post assessments that described the effectiveness of the medication at 8:30 AM. The post assessments were described as "same" at 1:15 PM, 5:45 PM and 7:20 PM. There was no further assessments for the effectiveness of the patient's pain medication.

Review of the medical record for patient #4 on 1/19/11 revealed a progress note identified by staff #C as 8/27/10 at 11:30 AM that revealed the patient had an intravenous infiltrate that prevented the administration of pain medication ordered via pump for a one and one half hour time period. The record revealed there had been multiple attempts to restart the intravenous line. There was no documented evidence of an assessment that described the extent of the infiltration. There was no documented how many intravenous attempts were made and how many staff made attempts to restart this patient's intravenous Interview of Staff C on 1/19/11 at 3:00 PM revealed it would be expected that the nurses assess the infiltrate. Interview of Staff G on 1/20/11 at 11:45 AM revealed the verbal hospital protocol is that only two attempts at starting an intravenous access were permitted per staff.


07973

Patient #2's medical record was reviewed on 01/18/11. This patient was admitted for total hip replacement on 08/02/10. Medical record review revealed that pain medication was given on 08/02/10 at 5:57 PM for pain documented at the level 7/10, but there was no documentation or effectiveness of pain medication. Pain medication was also given on 08/04/10 at 10:20 AM for pain level 7/10, at
2:10 PM for pain level of 8/10, and 6:30 PM for pain level of 6/10. None of the three pain medication entries on 08/04/10 had follow-up documentation in regard to effectiveness of the medication.