HospitalInspections.org

Based on document review and staff interview, it was determined that for 72 of 72 inpatients on 5/21/18, the hospital failed to provide the patient or the patient's representative with an accurate phone number and address to file a grievance with the State agency. Findings included:

During an interview on 5/21/18 at 1:59 PM, Infection Preventionist/Quality Assurance A reported that patients were advised of their right to file a grievance in the document entitled "Patient Safety and Quality Concerns".

Review of the document entitled "Patient Safety and Quality Concerns" revealed that the State Agency's address and telephone number were inaccurate/incomplete.

This finding was confirmed by Infection Preventionist/Quality Assurance A on 5/21/18 at 1:59 PM.

Based on medical record review, policy review and staff interview, it was determined that nursing staff failed to evaluate the nursing care for 2 of 5 patients (Patient #'s 1 and 2) in the sample. Findings included:

The hospital policy entitled "Pain Management" stated, "...patients will be evaluated for pain...reassessed with every vital sign assessment; with any complaint of pain and within 1 hour after treatment for pain..."

The hospital "Job Description" for the Staff Registered Nurse (RN) documented the following, "...Adheres to hospital nursing practice standards...Recognizes the need for effective pain management...and documents...Ensures that physician orders are executed promptly, completely and accurately..."

Medical record review revealed:

A. Patient #1

1. Physician order dated 4/10/18 at 4:46 PM:
- Oxycodone 10 mg (milligrams) as needed every 3 hours for pain that was rated 7 - 10 (0 = no pain, 10 = worst possible pain)

2. "Medication Administration Record (MAR)" and nursing notes documented that Oxycodone 10 mg was administered for pain that was rated less than 7 on 4/11/18 at the following times:
3:24 AM (pain level of 6)
1:53 PM (pain level of 5)

3. No evidence that the patient's pain was re-assessed on 4/11/18:
- after the administration of Oxycodone at 1:53 PM
- when vital signs were assessed at 3:51 PM and 10:31 PM

These findings were confirmed with Informatics RN A and Acting Quality Director A on 5/22/18 at 11:37 AM.

B. Patient #2

1. "MAR" and nursing notes documented that pain medication was administered for pain that was rated as follows:

1/16/18 5:07 PM: Ibuprofen 800 mg (pain level of 6)
1/17/18 5:48 PM: Ibuprofen 800 mg (pain level of 5)
1/18/18 3:04 AM: Oxycodone 10 mg (pain level of 5)

2. No evidence that the patient's pain was re-assessed until the following times which were greater than 1 hour:
1/16/18 at 9:36 PM (4 hours 32 minutes later)
1/17/18 at 9:07 PM (3 hours 20 minutes later)
1/18/18 at 8:15 AM (5 hours 13 minutes later)

These findings were confirmed by Informatics RN A on 5/22/18 between 12:15 PM and 12:30 PM.

Based on medical record review, policy review and staff interview, it was determined that staff failed to develop a nursing care plan for 3 of 5 patients (Patient #'s 3, 4 and 5) in the sample. Findings included:

The hospital policy entitled "Patient Assessment Policy" stated, "...patient will have...needs...assessed by a registered nurse...Interdisciplinary Plan of Care (IPOC) will be initiated within 4 hours of patients admission. These provide the basis for formulating the patient plan of care..."

Medical record review revealed no evidence that a nursing plan of care was developed during the hospitalization of Patient #'s 3, 4 and 5.

1. Patient #4 (hospitalized 4/4 - 4/10/18)

This finding was confirmed by Informatics RN (registered nurse) A and Acting Quality Director A on 5/22/18 at 12:47 PM.

2. Patient #3 (hospitalized 4/9 - 4/11/18)

This finding was confirmed by Informatics RN A and Acting Quality Director A on 5/22/18 at 12:48 PM.

3. Patient #5 (hospitalized 4/3 - 4/10/18)

This finding was confirmed by Informatics RN A and Acting Quality Director A on 5/22/18 at 1:00 PM.

Based on medical record review, policy review and staff interview, it was determined that entries in the medical record were not accurate for 1 of 5 patients (Patient #2) in the sample. Findings included:

The hospital policy entitled "Documentation Requirements in the Medical Records" stated, "...Accurate and complete recording of patient care and treatment..."

The hospital policy entitled "Patient Assessment Policy" stated, "...Pharmacy...A medication profile is maintained for each patient to facilitate continuity of care, provide necessary drug information to create an accurate medication history...help assure safe administration of medications..."

A. Review of Patient #2's medical record revealed:

1. Physician orders dated 1/15/18 at 4:43 AM
- Oxycodone 10 mg (milligram) tablet every 6 hours, PRN (as needed) pain, severe

2. Physician orders dated 1/16/18 at 3:15 PM
- Oxycodone 10 mg tablet every 4 hours, PRN pain, severe

3. Conflicting orders for Oxycodone (every 4 hours and every 6 hours)

During an interview on 5/22/18 at 12:40 PM, Acting Quality Director A:
- confirmed these findings
- reported that the conflicting order was also missed by the pharmacy