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Based on interview and record review, the hospital failed to ensure that a History and Physical (a critical component of a patient encounter in which information relevant to a present complaint is obtained) was completed for 1 of 40 sampled patients (Patient 1) within 24 hours of her admission to Hospital A. The lack of a history and physical in a patient's medical record could hinder health practitioners in their treatment plan for the patient due to the lack of documentation of the patient's past medical history, allergies, comorbitities (existing medical diagnoses), and overall medical condition.

Findings:

Patient 1 was admitted to the hospital on 10/29/13 with a diagnosis of bilateral leg wounds, according to the Admission Facesheet. A review of Patient 1's medical record was conducted on 11/4/13 at 10:45 A.M. There was no evidence in Patient 1's medical record that her attending physician had either written or dictated a complete History and Physical.

A review of the hospital's Medical Staff Bylaws indicated that "Completion of a physical examination and medical history shall be done within twenty-four (24) hours after admission. This requirement may be satisfied by a complete history and physical that has been performed within 30 days prior to admission, so long as an examination for any changes in the patient's condition is completed and documented (interval note) in the medical record within twenty-four (24) hours after admission, but prior to surgery or a procedure requiring anesthesia services."

An interview was conducted with the Director of Patient Safety (DPS) on 11/4/13 at 11:25 A.M. The DPS stated that Patient 1's attending physician was currently in the process of dictating the History and Physical. That occurred seven days after Patient 1 was admitted to Hospital A. The DPS further explained that Patient 1's attending physician was not following the hospital's Medical Staff Bylaws regarding a History and Physical dictated or written for each patient within 24 hours of the patient's admission to the hospital.

Based on interview and record review, the hospital failed to ensure that pain medication was administered, as ordered, by the physician for 2 of 40 sampled patients (Patient 1, 8). Both patients were admitted to Hospital A. Failure to administer pain medications, as ordered by the physician, could lead to a lack of pain control for the patient, as intended by the physician's medical treatment plan.

Findings:

1. Patient 1 was admitted to Hospital A on 10/29/13 with a diagnosis of bilateral leg wounds according to the Admission Facesheet. A review of Patient 1's medical record was conducted on 11/4/13 at 10:45 A.M. According to the physician's orders, the following pain medications were to be administered to Patient 1 for control of her leg pain:

Ordered on 10/29/13 at 12:00 P.M., Norco (a narcotic pain reliever) 5/325 po (by mouth) q (every) 4h prn (as required) pain.

There were no pain parameters associated with this physician's order.

Ordered on 10/29/13 at 5:50 P.M., Dilaudid (a narcotic pain reliever used to treat moderate to severe pain) 1 mg (milligram) IV (intravenous) Q (every) 2 hours prn (as required) severe pain.

A review of the hospital's policy and procedure, entitled "Pain Management" and dated 5/12, indicated that severe pain equaled a pain level of 7 to 10.

A review of the hospital's policy and procedure, entitled "Medication Use: Range Orders and PRN Order Clarification" and dated 12/12, indicated that "If multiple medications are written for the same indication, but have different routes, the medication orders do not need to be clarified (ex: Morphine 1 mg IVP prn pain and Percocet 1 tablet PO prn pain) The nurse will administer the medications based on the following table: Oral: Use as first option when oral is tolerated by patient. If more rapid treatment of symptoms is needed, may use an injectable route.

There was documentation present on the pain assessment flowsheet of Patient 1's electronic medical record that on 11/3/13 at 8:35 A.M., Patient 1 verbalized to her Registered Nurse (RN 1) a pain score of 8. RN 1 administered Norco 1 tablet orally to Patient 1. At 10:27 A.M. on 11/3/13, Patient 1's pain level was still at 8 so RN 1 administered Dilaudid 1 mg IV.

A review of the hospital's policy and procedure, entitled "Medications: Orders, Administration, and Documentation" and dated 10/12, indicated that medications are administered in accordance with the written or electronic order of a licensed independent practitioner (LIP)."

On 11/4/13 at 11:25 A.M., an interview was conducted with the Director of Patient Safety (DPS). The DPS stated that RN 1 did not administer pain medication to Patient 1 in accordance with the physician's order.

An interview was conducted with RN 1 on 11/4/13 at 3:00 P.M. RN 1 stated that she used the physician's parameters for pain medication to know what pain medication to administer. RN 1 reviewed Patient 1's pain assessment flow sheet for 11/3/13 and stated that she should have administered Dilaudid 1 mg IV to Patient 1 at 8:45 A.M.

2. Patient 8 was admitted to Hospital A on 11/3/13 with a diagnosis of three right sided fractured ribs, following a fall at home, according to her admission History and Physical. A review of Patient 8's medical record was conducted on 11/5/13 at 8:55 A.M.

According to the physician's orders, the following pain medications were to be administered to Patient 8 for control of her fractured rib pain:

Ordered on 11/3/13 at 10:05 P.M., Hydrocodone 5 mg (milligrams)/Acetaminophen 325 mg (NORCO - a narcotic pain reliever) 1 tab (tablet) PO (by mouth) every 4 hours PRN (as required) moderate pain and, Morphine Sulfate (opiate analgesic used to relieve severe pain) 2 mg IVP (intravenous push) every one hour prn pain. There were no pain parameters written for the administration of the Morphine Sulfate.

A review of the hospital's policy and procedure, entitled "Pain Management" and dated 5/12, indicated that moderate pain equaled a pain level of 4 to 6.

A review of the hospital's policy and procedure, entitled "Medication Use: Range Orders and PRN Order Clarification" and dated 12/12, indicated that "If multiple medications are written for the same indication, but have different routes, the medication orders do not need to be clarified (ex: Morphine 1 mg IVP prn pain and Percocet 1 tablet PO prn pain) The nurse will administer the medications based on the following table: Oral: Use as first option when oral is tolerated by patient. If more rapid treatment of symptoms is needed, may use an injectable route.

There was documentation present on the pain assessment flowsheet of Patient 8's electronic medical record that on 11/4/13 at 10:07 A.M. Patient 8 verbalized to her Registered Nurse (RN 8) a pain score of 10. RN 8 administered Norco 1 tablet orally to Patient 1. At 4:03 P.M. on 11/4/13, it was documented that Patient 8 was experiencing pain at the level of 8. Again, RN 8 administered Norco 1 tablet orally to Patient 8.

A review of the hospital's policy and procedure, entitled "Medications: Orders, Administration, and Documentation" and dated 10/12, indicated that medications are administered in accordance with the written or electronic order of a licensed independent practitioner (LIP)."

An interview was conducted with RN 8 on 11/5/13 at 3:15 P.M. RN 8 explained that a moderate pain level would be when a patient verbalized pain at a level of 4 to 6. RN 8 acknowledged that she should have administered Morphine 2 mg IVP to Patient 8 when she complained of pain at a level of 10 and, then, later at a level of 8.