HospitalInspections.org

20771

Based on review of hospital policies/procedures, medical records, hospital documents and interviews, it was determined that the nursing staff failed to conduct and document pain management interventions and assessments for 2 of 4 patients (patients #'s 11 and 12) as demonstrated by:

1. failure to clarify physicians' orders for pain medication appropriate to 1 of 4 patient's level of pain (Patient #11);

2. failure to document 2 of 4 patients' pre and post pain medication administration assessments (Patients #'s 11 and 12); and

3. failure to medicate 1 of 1 patient for pain according to physician's orders (Patient #11).

Findings include:

The hospital policy titled Ordering of Medications #H-MM30-001 (last revised 04/12), requires: "...Pain: a numeric range will be assigned to the descriptors mild, moderate, severe... Mild:..0-3...Moderate:..4-7...Severe:..8-10...."

1. Patient #11 was admitted on 07/16/13 for extensive wound care management, according to the medical record. The physician ordered: "Oxycodone 10 mg PO (oral) Q (every) 4 hours PRN (as needed) for MODERATE pain." Nursing documented:

07/17/13 (1940): Pain 8/10. The nurse administered Oxycodone 10 mg PO according to the physician's order for MODERATE pain. There was no documentation that the nurse contacted the physician to clarify/confirm orders to address SEVERE pain.

The Northwest Director of Quality Management (DQM) and the RN Information Technology (RN IT) confirmed during interviews conducted on 07/24/13, no documentation that the nurse notified the physician of the patient's reported SEVERE pain and clarified medication orders for such.

2. Patient #11's medical record revealed the following:

07/16/13 (0004): Pain 8/10 (severe). No interventions documented. The patient was not reassessed for 9.75 hours.

07/17/13 (2141): Pain 6/10 (moderate). No interventions documented. The patient was not reassessed for 10 hours.

07/18/13 (0814): Pain 6/10. The nurse administered Morphine Sulfate (MS) 2 mg IV per physician's order for MODERATE pain. At (0843) the patient's pain relief was "effective." The nurse did not document a numerical pain level or otherwise indicate what the patient's activities or assessment was at the time. In addition, the patient indicated during an interview conducted on 07/25/13, that she rates her pain numerically (1-10).

Patient #12 was admitted on 07/14/13 for extensive wound care management, according to the medical record. Documentation revealed the following:

07/24/13 (0920): Pain 7/10. Nursing administered Oxycodone IR 5 mg PO
07/24/13 (1000): Pain 10/10 (reassessment)
07/24/13 (1011): Nursing repeated Oxycodone IR 5 mg PO

07/24/13 as of 1515, there was no further documentation of pain reassessment.

The DQM and the RN IT verified during interviews conducted on 07/24/13 at 1500, no documentation that identified or accounted for the lack of reassessment documentation.

3. Patient #11's physician ordered Acetaminophen 650 mg PO for temperature greater than 101 degrees. Documentation revealed the following:

07/18/13 (1021): Pain 6/10. Nursing administered Acetaminophen 650 mg PO. At 1108, the nurse documented, "effective." The patient was afebrile when she was medicated for pain with the Acetaminophen.

The DQM and RN IT verified during interviews conducted on 07/24/13 at 1500, that the patient's only temperatures documented between 1021 and 1108 were; (0700) 97.3. and (1130) 97.9. The nurse did not follow the physician's orders for pain management and administered medication ordered for fever.