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Based on clinical record review, staff interview and policy review it was determined the RN did not supervise the care and did not evaluate the care of one (#1) of four sampled patients on an ongoing basis to ensure the patients needs were met.


Findings Included :


(1). Patient #1 presented to the emergency department on 8/30/10 with complaints of lung pressure and shortness of breath. The patient's pain score was 8 out of 10 on a scale of 0-10 with 10 being the worst. The patient was examined by the ED Physician at 4:50 p.m. The patients past medical history was listed as lung cancer, hypothyroid, and craniotomy secondary to brain tumor. The patient was complaining of chills, sweating, left sided chest pain, light-headedness and cough. A review of the ED physician's orders revealed that no pain medications were ordered for the patients 8 out of 10, left sided chest pain. A review of the patient's admission orders dated 8/30/10 at 7:20 p.m. revealed an order for Tylenol 650 milligram (mg) every 6 hours for pain or temperature greater than 100.4 degrees. A review of the ED records revealed the Tylenol was not given for either pain or fever.

(2). The Admission Database completed by a Registered Nurse on 8/30/11 at 9:55 p.m. revealed the patient was experiencing sharp chest and back pain, the intensity of pain was listed as a 7 out of 10 and the score the patient would like to achieve is listed as "0". The next pain assessment was completed on 8/31/10 at 8:30 a.m., the pain scale is listed as 6 out of 10, a "Y" is listed in the acceptable column, quality was aching, time pattern was intermittent and interventions was listed as "rest". Another pain assessment was completed at 2:30 p.m., the pain score was now a "7", there was a "N" for acceptable, the quality was aching, the pattern was constant, and the intervention was "resting". On 9/3/10 a pain assessment was completed at 8:00 a.m., the pain level was a "5", the quality was aching, the pattern was intermittent and the interventions was "resting". A review of the nursing "Patient Progress Record", dated 8/31/10 through 9/3/10 did not reveal any nursing notification of the patient's pain to the Physician.
The patient's admission Database for her second admission dated on 3/8/11 at 6:35 p.m. was completed by an Licensed Practical Nurse. The Database was not reviewed or signed by an Registered Nurse.

(3). The Medication Administration Record's ( MAR) dated 8/30/10 to 9/3/10 the date of discharge, did not reveal any medication given specifically for pain relief.

(4). The Physicians progress record dated 8/30/10 to date of discharge 9/3/10 did not reveal any pain assessment. A review of the Physicians orders for the same dates did not reveal any medication orders for pain medication.

(5). The Adult Clinical Flow sheet, Plan of Care/Problem list, revealed none of the problems, including Pain/comfort was "met" prior to discharge. A review of the Discharge instructions record, section for "Problems on Plan of Care resolved, yes or no" neither was checked as resolved.

(6). An interview was conducted on 5/13/11 with the Director of Nursing, after a thorough review of the patients clinical record confirmed the patient had been medicated for her temperature, but there was no pain medication ordered or addressed with either nursing or physicians. The Director of Nursing indicated the "y" stood for yes the pain was tolerable for the patient. There was no further documentation in the clinical record to indicate the patient was assessed appropriately, offered pain medication and/or refused the medication.
(7). A review of the facility's policy, "Pain Management", policy # 100.185.86, effective 10/2010, was conducted on 5/12/11. "Patients will be assessed for the presence of pain, re-assessed at regular periods thereafter, and receive appropriate pain management throughout their hospital." All patients will be initially assessed for the presence, absence, and history of pain. The initial assessment for pain includes: Site, Intensity, Duration, Type/quality, Impact, alleviating measures, aggravating factors, cultural/personal or ethical beliefs, nonverbal cues and Patient's personal goal for pain relief.

(8). A review of the policy "Patient Care Process", policy # 100.185.74, effective date 8/2009, revealed under Assessment, 1) each patient's need for Nursing Care is assessed by a Registered Nurse (RN). On page 3 of 3, paragraph for "Evaluation", revealed the RN will review/update the Plan of Care /Problem List once every 24 hours. (2) Evaluation will include observations and analysis of patient's immediate response to interventions as well as response over a period of time. (3) Priorities may be changed. If expected outcomes have been achieved, the problem is resolved and note as "Met". (5) Patient's status at the time of discharge will be noted on the Discharge Instructions Record and (6) Problems not resolved at discharge will be referred as appropriate.