HospitalInspections.org

Based on medical record reviews, staff interview and review of policy and procedures it was determined the facility failed to ensure a registered nurse supervised and evaluated the nursing related to assessments for three (#2, #4, #10) of ten patients sampled.

Findings included:

1. Review of the facility policy "Pain Management Plan", H-PC 04-004, indicated when pain is identified, assessment and documentation shall include pain scale rating, location, duration, intensity and character.

Review of the medical record for patient #4 revealed the patient had a physician order for Morphine 2 mg (milligrams) IV (Intravenous) every 4 hours as needed. Review of the MAR (Medication Administration Record) revealed on 3/18/2016 at 9:22 a.m. the patient was administered Morphine 2 mg IV. Review of nursing documentation revealed no evidence of the patient's pain scale rating, location, duration, intensity or character. On 3/18/2016 at 2:55 p.m. the patient was administered Morphine 2 mg IV. Review of nursing documentation revealed no evidence of the patient's pain scale rating, location, duration, intensity or character.

On 3/22/2016 at approximately 9:45 a.m. an interview with the CCO (Chief Clinical Officer) was conducted. The CCO reviewed the patient's record and confirmed the above findings.

2. Review of the medical record for patient #2 revealed a physician order for Xanax 0.5 mg daily prn (as needed). Xanax is a benzodiazepine medication used to treat anxiety and panic disorders. Review of the MAR revealed the patient was administered Xanax on 2/17/2016 at 2:46 p.m. Review of nursing documentation revealed no evidence of a patient assessment or documentation of the patient's signs and symptoms requiring administration of the Xanax.

Review of the medical record for patient #10 revealed a physician order for Fentanyl IV drip, titrate to keep patient sedated and pain free with a RIKER scale of 4. Review of the record revealed a nursing order to perform a RIKER Scale assessment every 2 hours. Review of the nursing documentation revealed on 3/15/2016 at 12:11 p.m. the Fentanyl drip was initiated. Review of the 3/15/2016 night shift (7:00 pm through 7:00 am) nursing documentation revealed the nurse performed a RIKER scale assessment at 11:00 p.m. There was no other RIKER scale assessment during the night shift. On 3/16/2016 review of the day shift (7:00 am through 7:00 pm) nursing documentation revealed the nurse performed a RIKER scale assessment at 10:01 a.m. and did not perform another RIKER scale assessment until 3:30 p.m.

On 3/22/2016 at approximately 11:55 a.m. an interview with the CCO was conducted. The CCO reviewed the patient's records and confirmed the above findings.