HospitalInspections.org

Based on a review of facility documents, medical record reviews (MR) and staff interview (EMP), it was determined the facility failed to evaluate and treat a patient's complaint of pain for one of 10 medical record reviewed (MR1).

Findings include:

Review on October 18, 2016, of the facility Patient Rights and Responsibilities brochure, last reprinted April 2015, revealed, "As a patient at Susquehanna Health, it is important to realize that you have both rights and responsibilities. This summary of patients' rights and responsibilities describes how you can participate in receiving quality care and reflects our commitment to ensuring that our patients, their families and friends are treated with respect, understanding and compassion. We encourage you to discuss this list with your doctor and other members of the healthcare team. ... Treatment Your Rights Are: ... To have your pain evaluated, treated and managed appropriately. ... ."

Review on October 18, 2016, of the facility Therapy Pain Policy, last revised November 2015, revealed, "Purpose: To acknowledge inpatient and outpatient therapy's (Physical, Occupational, Speech) commitment to the pain management of their patients. To establish a pain monitoring process that results in appropriate, timely, efficacious, and safe pain management of reach patient throughout the continuum of care. Principles 1. Every patient has the right to adequate pain management. They also have the right to refuse any proposed means of pain intervention. ... 2. Pain control is a legitimate therapeutic goal that contributes significantly to an individual's physical, functional and emotional well-being. 3. Pain is whatever the individual says it is and exists whenever the individual says it does ... 4. The patient is the final authority on judging their pain and should be involved in decisions regarding methods of pain control. Guidelines ... 4. The therapist will evaluate any pain that results in inability to participate in therapy or that significantly increases during therapy and verbally communicate that to nursing staff (inpatient setting only) if therapeutic interventions/modalities prove ineffective. ... 5. All therapeutic attempts to relieve pain should be documented in detail, as should the detail of the notification with nursing staff (inpatient setting only). ... ."

Review of MR1 on October 18, 2016, revealed Physical Therapy (PT) documentation dated September 12, 2016, at 8:58 AM indicating MR1 was not able to tolerate full weight bearing through the left leg due to pain and that this patient was insisting on returning to bed; MR1 had decreased strength and increased pain limiting transfers and functional mobility; this patient had pain with the initial transfers and that MR1 did not attempt ambulation due to the inability to shift weight to be able to perform gait training. There was no documentation in this patient's medical record indicating PT notified nursing staff regarding MR1's left leg pain, was unable to tolerate weight bearing and was unable to perform transfers.

Interview with EMP3, EMP4 and EMP5 on October 18, 2016, at approximately 12:30 PM confirmed PT's documentation that MR1 was not able to tolerate full weight bearing through the left leg due to pain and that this patient was insisting on returning to bed; had decreased strength and increased pain limiting transfers and functional mobility; had pain with the initial transfers and that MR1 did not attempt ambulation due to the inability to shift weight to be able to perform gait training. EMP3, EMP4 and EMP5 confirmed there was no documentation in this patient's medical record indicating PT notified nursing staff regarding MR1's left leg pain, was unable to tolerate weight bearing and was unable to perform transfers.

Review of MR1 on October 18, 2016, revealed Occupational Therapy (OT) documentation dated September 12, 2016, at 8:58 AM indicating MR1 quickly becomes agitated by pain in the leg and is very limited by the pain in the upper leg requiring maximum assistance of two persons. There was no documentation in this patient's medical record indicating OT notified nursing staff regarding MR1 becoming agitated by pain in the leg and limited by pain in the upper leg requiring maximum assistance of two persons.

Interview with EMP3, EMP4 and EMP5 on October 18, 2016, at approximately 12:35 PM confirmed MR1's OT documentation that MR1 quickly became agitated with the pain in the leg and was limited by pain in the upper leg requiring maximum assistance of two persons. EMP3, EMP4 and EMP5 confirmed there was no documentation in this patient's medical record indicating OT notified nursing staff regarding this patient becoming agitated by pain in the leg and being limited by the pain in the upper leg requiring maximum assistance of two persons.

Review of MR1 on October 18, 2016, revealed PT documentation dated September 13, 2016, at 8:35 AM indicating MR1 did not attempt ambulation due to this patient inability to shift weight and perform gait training.

Review of MR1 on October 18, 2016, revealed OT documentation dated September 13, 2016, at 8:29 AM indicating MR1 stood but was unable to move and this patient was yelling with pain. There was no documentation in this patient's medical record indicating OT notified nursing staff regarding this patient's yelling with pain and inability to move.

Interview with EMP3, EMP4 and EMP5 on October 18, 2016, at approximately 12:30 PM confirmed OT's documentation that MR1 stood but was unable to move and this patient was yelling with pain. EMP3, EMP4 and EMP5 confirmed there was no documentation in MR1's medical record indicating OT notified nursing staff regarding this patient's yelling with pain and inability to move.

Interview with EMP1 and EMP3 on October 18, 2016, revealed it the facility's process for physician notification would be by nursing staff. EMP3 revealed PT and OT should have communicated MR1's pain to nursing staff. EMP1 revealed nursing staff would then medicate the patient and notify the patient's physician if pain relief was not obtained.