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Based on review of facility policies and procedures, medical records and staff interviews, nursing staff failed to assess pain prior to administering pain medications and/or reassess pain after an intervention for 3 of 8 records reviewed (#3, #9, #10).

Findings included:

Review on 12/14/2011 of facility policy "Pain Assessment/Management" dated 03/2006 revealed "II. Reassessment of Pain:...4. After any active pain management intervention, pain score must be reassessed within 2 hours...III. Documentation...2. Document pain rating score pre- and post each intervention."

1. Closed record review on 12/14/2011 for Patient #3 revealed a 40 year old admitted 04/10/2011 for asthma. Review revealed the patient was prescribed Percocet for pain management. Review revealed the patient received a dose of Percocet on 04/10/2011 at 2220 for pain of 8 on a 10 point scale (with 10 being most severe pain). Review revealed the next pain reassessment was at 0505 on 04/11/2011 (6 hours and 45 minutes after pain medication administered). Review revealed the patient received a dose of Percocet on 04/11/2011 at 2255 (pain assessment not documented at time of medication administration). Review revealed the next pain reassessment was at 0800 on 04/12/2011 (9 hours and 5 minutes after pain medication administered). Review revealed the patient received a dose of Percocet on 04/12/2011 at 1000 (pain assessment not documented at time of medication administration). Review revealed the next pain reassessment was at 1922 on 04/12/2011 (9 hours and 22 minutes after pain medication administered). Review revealed the patient received a dose of Percocet on 04/12/2011 at 2049 (pain assessment not documented at time of medication administration). Review revealed the next pain reassessment was at 0800 on 04/13/2011 (11 hours and 11 minutes after pain medication administered).

Interview with administrative staff on 12/14/2011 at 1440 revealed nursing staff should assess and document a patient's pain level using the pain scale prior to pain medication being administered and within two hours after the intervention. Interview revealed nursing staff failed to assess the patient's pain level prior to pain medication being administered to Patient #3 on 04/11/2011 at 2255, on 04/12/2011 at 1000, and on 04/12/2011 at 2049. Further interview revealed nursing staff failed to reassess Patient #3's pain within 2 hours after pain medication was administered on 04/10/2011 at 2220, on 04/11/2011 at 2255, on 04/12/2011 at 1000, and on 04/12/2011 at 2049. Interview failed to reveal any further documentation the patient's pain was assessed prior to or after the above pain interventions.

2. Closed record review on 12/14/2011 for Patient #9 revealed a 54 year old admitted 10/21/2011 for abdominal pain. Review revealed the patient was prescribed Vicodin for pain management. Review revealed the patient received a dose of Vicodin on 10/22/2011 at 1339 (pain assessment not documented at time of medication administration). Review revealed the next pain reassessment was at 2010 on 10/22/2011 (6 hours and 31 minutes after pain medication administered). Review revealed the patient received a dose of Vicodin on 10/22/2011 at 2204 for pain of 7 on a 10 point scale (with 10 being most severe pain). Review revealed the next pain reassessment was at 1800 on 10/23/2011 (19 hours and 56 minutes after pain medication administered). Review revealed the patient received a dose of Vicodin on 10/23/2011 at 0823 (pain assessment not documented at time of medication administration). Review revealed the next pain reassessment was at 0810 on 10/24/2011 (23 hours and 47 minutes after pain medication administered).

Interview with administrative staff on 12/14/2011 at 1440 revealed nursing staff should assess and document a patient's pain level using the pain scale prior to pain medication being administered and within two hours after the intervention. Interview revealed nursing staff failed to assess the patient's pain level prior to pain medication being administered to Patient #9 on 10/22/2011 at 1339 and on 10/23/2011 at 0823. Further interview revealed nursing staff failed to reassess Patient #9's pain within 2 hours after pain medication was administered on 10/22/2011 at 1339, on 10/22/11 at 2204 and on 10/23/2011 at 0823. Interview failed to reveal any further documentation the patient's pain was assessed prior to or after the pain interventions above.

3. Closed record review on 12/14/2011 for Patient #10 revealed a 25 year old admitted 11/05/2011 for anemia. Review revealed the patient was prescribed Percocet for pain management. Review revealed the patient received a dose of Percocet on 11/05/2011 at 1201 for pain of 5 on a 10 point scale (with 10 being most severe pain). Review revealed the next pain reassessment was at 1750 on 11/05/2011 (5 hours and 49 minutes after pain medication administered). Review revealed the patient received a dose of Percocet on 11/06/2011 at 1959 for pain of 8 on a 10 point scale. Review revealed the next pain reassessment was at 2236 on 11/06/2011 (2 hours and 37 minutes after pain medication administered).

Interview with administrative staff on 12/14/2011 at 1440 revealed nursing staff should assess and document a patient's pain level using the pain scale within two hours after the intervention. Interview revealed nursing staff failed to reassess Patient #10's pain within 2 hours after pain medication was administered on 11/05/2011 at 1201 and on 11/06/2011 at 1959. Interview failed to reveal any further documentation the patient's pain was assessed after the pain interventions above.

Based on review of facility policies and procedures, medical records and staff interviews nursing staff failed to develop a care plan for 1 of 8 records reviewed (#2).

Findings included:

Review on 12/14/2011 of facility policy "Interdisciplinary Plan of Care" dated 06/2010 revealed "1. The RN (registered nurse) will...Initiate the Interdisciplinary Plan of Care (IPC) on admission within 24-hours by identifying the patient's nursing diagnosis..."

Record review on 12/14/2011 for Patient #2 revealed a 50 year old admitted to the facility 04/11/2011 for cough and shortness of breath. Review revealed the document "Interdisciplinary Care Plan" had no identified problems, interventions or goals identified.

Interview with administrative staff on 12/14/2011 at 1430 revealed all records should have identified problems, interventions and goals. Interview revealed the IPC for Patient #2 was not completed per facility policy.

Based on review of facility policies and procedures, medical records and staff interviews, nursing staff failed to administer blood products with a physician's order for 1 of 5 records reviewed (#4).

Findings included:

Review on 12/14/2011 of facility policy "Transfusion Therapy" dated 12/2009 revealed "Procedure Steps...3. RN will verify physician order to transfuse blood/blood components."

Closed record review on 12/14/2011 for Patient #4 revealed a 85 year old admitted 11/11/2011 for chronic anemia. Review revealed a physician's order written 11/11/2011 at 1900 "...2. Transfuse 1 (one) unit of PRBCs (packed red blood cells)..." Review revealed the physician's order originally directed nursing to transfuse 2 units of PRBCs, however the order for two was formed into a number (1) with "(one)" written above and the word "units" corrected to "unit". Review revealed no date or time the order was modified or indication as to who made the order modification. Review of documentation revealed the patient received a blood transfusion on 11/11/2011 starting at 2115 and ending at 2350 on 11/11/2011. Further review revealed the patient received an additional blood transfusion on 11/12/2011 beginning at 0030 and ending at 0315 on 11/12/2011. Review failed to reveal any physician's order for the second blood transfusion.

Interview with administrative staff on 12/14/2011 at 1500 revealed there should be a physician's order for each unit of blood transfused. Interview revealed Patient #4 received two (2) units of blood. Interview revealed Patient #4 had a physician's order for only one (1) unit of blood. Interview failed to reveal any further documentation an order was obtained by nursing to transfuse the second unit of blood beginning at 0030 on 11/12/2011. Interview revealed nursing failed to follow facility policy by failing to administer blood products only with a physician's order.

NC00076475