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Based on medical record review, policy review and staff interview it was determined the registered nurse failed to supervise and evaluate nursing care and follow policy and procedure related to Patient Controlled Analgesia (PCA) Management for one (#2) of ten records reviewed.

Findings include:

Patient #2 underwent a surgical on 3/10/15. Pain management was via a PCA pump. On 3/11/15 at 12:30 p.m. the patient experienced respiratory distress requiring the use of Narcan and oxygen. The patient was was transferred to the intensive care unit (ICU) for further management.


Review of the nursing documentation on the Patient Controlled Analgesia flow sheet noted the last entry was on 3/11/15 was at 7 a.m. at the change of shift. The entry had no documented blood pressure or a co signature of another nurse. Review of the nursing assessment record revealed on 3/11/15 at 12:00 p.m. the vital signs were obtained. However, there was no documentation regarding the patient's sedation level and neurological assessment.

Review of the policy and procedure titled "Patient Controlled Analgesia (PCA) Management of the patient receiving" last revised 2/2011 stated on page 1, #2 Assess patient upon initiation and following each bolus or increase in narcotic dosage, assess every 2 hours X 2 and then every 4 hours a. Level of sedation and level of pain using 0-10 numerical scale. b. Monitor for side effects of narcotic therapy. c. Medication balance. d. Number of actual doses received by the patient compared to the numbers of actual attempts.

Review of the policy titled "Patient Controlled Anesthesia (PCA)" policy number 4.22, with last revision date of 12/2011 stated on page 1 of 1 paragraph E the patient is monitored for pain relief, sedation level, side effects, respiratory rate and blood pressure, number of attempts, number of actual doses every four hours, upon initiation, or more frequently as patient condition warrants. For each observation, assessment and medication balance should be documented on the PCA flow sheet. Paragraph F stated the PCA prescription, amount of medication in the bag, and the pump settings will be verified and signed by two nurses on the flow sheet on initiation, at each shift change and with each dosage change. Paragraph L stated the physician will be notified of an increasing level of sedation, a dropping blood pressure ,a respiratory rate of less then eight, an inability to maintain an adequate level of pain relief.

The findings were confirmed with the Assistant Chief Executive Officer on 4/21/15 at approximately 12:45 p.m. related to nursing assessment and documentation of the patient receiving Patient Controlled Analgesia.