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Based on review of medical records and facility documents the facility failed to ensure that nursing staff consistently documented pain assessments and results of pain medication, use of respiratory support equipment, and unwitnessed falls and the required actions and patient assessments required after a patient fall. The nursing staff failed to consistently document the clinical information in 11 of 20 sample patients (#1, #2, #3, #7, #10, #11, #14, #15, #17, #19, #20). The failures created the potential for negative patient outcomes.

Findings:

1. The hospital nursing staff failed to comply with the policy/procedure entitled "Pain Assessment and Management" for 8 sample patients (#1, #2, #3, #10, #11, #14, #15, #20).

a) Review of the medical records for sample patients #1, #2, #3, #10, #11, #14, #15, #20 revealed that all had documented pain management issues and were prescribed medications for pain. In most cases, the pain control was not consistently effective. The medical record did not contain consistent documentation of pain scores or other descriptors of the patients' pain prior to medication and after medication, as required in the
"Pain Assessment and Management" policy.

b) Review of the policy/procedure entitled "Pain Assessment and Management" revealed the following, in part:
"POLICY:
To provide a means for assessing pain throughout the hospital that is consistent and complete for all patients with pain regardless of the cause. The patient will participate in identifying and controlling his/her level of pain.
PROCEDURE:
All patients will be assessed for pain utilizing interviews, physical assessments, and tools(pain scale, Wong/Baker faces scale) upon admission, and then PRN thereafter. The patient has the right to be as free of pain as possible.

PLEASE NOTE THAT THE BEST INDICATOR OF THE EXISTENCE AND LEVEL OF PAIN/DISCOMFORT IS THE PATIENT'S SELF REPORT. THE PATIENT'S SELF REPORT SHOULD BE BELIEVED AND DOCUMENTED AS SUCH.

A. A thorough assessment of pain will be made by the RN on admission and reassessment will be done at least every shift and PRN if pain is identified. Reassessment will be done anytime a patient has a change in pain status; i.e., post-op, post-procedure, change in condition, acute process, chronic pain.
B. The nurse must assess the patient pain before and then 30 minutes after the pain medication has been given. Use of the pain face scale may assist in consistently identifying the patient's response. Before and after pain assessment must be stated on the MAR.
3. Level of pain - using 1-10 scale or Wong/Baker faces scale.
10. Document all pertinent information in the nursing assessment and on the progress notes as appropriated. Notify the physician when pain is out of comfort zone for patient.
14. Report pain level greater than 6 which indicates increased pain, and/or unrelieved pain, and/or side effect to the physician managing the pain.
18. If in the process of assessment it is determined that the patient may be drug seeking; i.e. chemical dependency patients, the multidisciplinary treatment team will develop a pain plan under the direct supervision of the attending physician."

2. The hospital nursing staff failed to document in the medical record episode of unwitnessed falls reported by 2 sample patients (#7, #10)

a) Review of hospital event reports revealed that there were instances of unwitnessed falls in sample patients #7 and #10. Review of the medical records for these patients revealed no documentation of the unwitnessed falls and the required actions, assessments and notifications required in the hospital policy/procedure entitled "Fall Prevention Guidelines."

b) Review of the hospital policy/procedure entitled "Fall Prevention Guidelines" revealed the following, in part:
"7.0 Staff response and notification if a fall occurs:
7.1 Assess patient for any injuries.
7.2 Notify physician if any injury or suspected injury.
7.3 If patient not on fall precautions, implement immediately, including yellow non-skid socks.
7.4 Notify family of fall and any injuries.
7.5 Document fall, assessment, injuries and notifications in medical record."

3. The hospital nursing staff failed to consistently document the use of respiratory equipment/support in the medical record for 2 sample patients (#17, #19).

a) Review of the medical records for sample patients #17 revealed that the patient had obstructive sleep apnea that required the patient to use a "C-PAP" machine during sleep. The record indicated that the patient was compliant with use of the device, but the use of the device was only documented once on the night shift nursing notes throughout the patient's 9-day hospitalization.

b) Review of the medical record for sample patient #19 revealed that the patient had a medical syndrome that caused him/her to have blood oxygen de-saturation at higher altitude, requiring supplemental oxygen. The physician ordered oxygen per nasal cannula to be titrated to achieve a specified target blood oxygenation level. The patient was also noted to be non-compliant with his/her oxygen use at times. The record did not contain consistent documentation of the patient's use of oxygen.

4. The hospital nursing staff failed to comply with the policies/procedures and documentation expectations for the department of nursing services in the 11 sample records (#1, #2, #3, #7, #10, #11, #14, #15, #17, #19, #20) described above, that failed to adequately and consistently document pain assessments and results of pain medication, use of respiratory support equipment, and unwitnessed falls and the required actions and patient assessments required after a patient fall.

a) During multiple interviews during the survey, the Director of Nursing confirmed the findings in the records, and stated that the lack of documentation in the areas identified in the 11 sample records (#1, #2, #3, #7, #10, #11, #14, #15, #17, #19, #20), did not meet the expectation outlined in the hospital policies/procedures.

Based on review of medical records, facility documents and staff interviews, the hospital failed to ensure that nursing staff developed an revised care plans for all significant patient issues, including pain management, use of respiratory support equipment, lactation support, assessment after falls and use of restraints, seclusion and emergency medications for 8 of 20 sample patients ( #10, #11, #13, #14, #15, #18, #19, #20). The failures created the potential for negative patient outcomes

Findings:

1. The facility failed to develop and/or modify care plans for 5 patients (#10, #11, #14, #15, #20) that required effective pain management.

a) Review of the medical records for sample patients #10, #11, #14, #15 and #20 revealed that the patients were admitted with difficult to manage pain issues that were not addressed with specificity for each patient and there was not evidence of modification of the care plans when good pain control was not achieved.

2. The hospital failed to develop/modify care plans for 2 patients ( #13 and #18) for which seclusion, restraints and/or involuntary emergency medications were utilized.

a) Review of the medical records for sample patient #13 revealed that the patient received involuntary emergency medications for 7 days and some seclusion and physical or mechanical restraints were also utilized for brief episodes during that time. The form "Master Treatment Plan Modification (to be completed after each episode of locked seclusion each episode of locked seclusion/restraint)" was only completed once during that time.

b) Review of the medical record for sample patient #18 revealed that the patient was restrained, placed in seclusion and/or received involuntary emergency medications on 4 different occasions and the form "Master Treatment Plan Modification (to be completed after each episode of locked seclusion each episode of locked seclusion/restraint)" was only completed twice instead of the 4 times required.

c) Review of the policy/procedure entitled "Seclusion and Restraint" revealed the following, in parts:
"15.0 Treatment Plan Review/Revision:
When the patient has presented behavior that is dangerous to themselves or others so that restraint/seclusion were indicated, a review and modification of the treatment plan is indicated. Based upon the consultation with the attending physician or LIP (Licensed Independent Practitioner), information gathered from the debriefing with the patient, and the 1-hour face-to-face assessment, the RN shall review and update the treatment plan within 8 hours. The entire treatment team will review the plan at the next scheduled review. The updated treatment plan shall reflect:
15.1 The identification of an assessed problem associated with the use of restraint/seclusion.
15.2 Goals related to prevention of the further use of restraint/seclusion
15.3 Interventions which define alternative approaches to address the identified problem. Responsibility for each intervention is assigned.
15.4 Review of the plan with the patient.

16.4 Treatment plan review/revision following the episode of restraint/seclusion. The treatment plan revision will include interventions to prevent future use."

3. The hospital failed to develop/modify care plan for 1 patient ( #19) for use of oxygen to manage a chronic blood oxygen de-saturation condition.

a) Review of the medical record for sample patient #19 revealed that the patient had a medical syndrome that caused him/her to have blood oxygen de-saturation at higher altitude, requiring supplemental oxygen. The physician ordered oxygen per nasal cannula to be titrated to achieve a specified target blood oxygenation level. The patient was also noted to be non-compliant with his/her oxygen use at times. The care plan did not reflect the specific and changing targets for blood oxygenation and did not address the patient's non-compliance with the oxygen use. There were no identified interventions to attempt to increase patient compliance.

4. The hospital failed to develop/modify the care plan for 1 patient (#11) that had stopped nursing precipitously because of psychiatric decompensation and admission.

a) Review of the record for sample patient #11 revealed that the patient was a nursing mother that had ceased nursing 48 hours prior to admission for an acute psychotic episode. The patient's care plan did not address the care of the patient's engorged breasts and subsequent pain. The daily nursing notes contained some directions about expressing milk and using a breast pump per the internal medicine physician orders, but these interventions were not incorporated into the care plan. The care plan also did not clarify whether the treatment was geared to helping the patient stop nursing or to preserve her milk supply, and there was no discussion of the safety of the breast milk for the infant, since the patient was on numerous medications that might have been transmitted through the breast milk to the infant. There was also no discussion in the care plan of the patients ability to handle the responsibility of nursing in her current situation going forward.

5) The hospital failed to ensure that staff complied with the policy/procedure entitled "Interdisciplinary Inpatient Treatment Plan" for
8 sample patients ( #10, #11, #13, #14, #15, #18, #19, #20).

a) Review of the policy and procedure entitled "Interdisciplinary Inpatient Treatment Plan" revealed the following, in part:
"PURPOSE;
1. To provide a complete, individualized, plan of care based on an integrated assessment of the patient's specific needs and problems, and prioritization of those needs/problems.
2. To provide appropriate communication between team members that fosters consistency and continuity in the care of the patient.
3. To formulate a plan of care that meets the patient's objectives and needs.
POLICY:
Each patient admitted to the hospital shall have a written, individualized treatment plan. Based on assessments of clinical needs, the plan shall describe patient strengths and disabilities; goals and objectives; clinical interventions prescribed; patient progress in meeting treatment goals and objectives; criteria for termination of treatment; and provision for aftercare. Treatment shall be planned, reviewed and evaluated at regular intervals by a Multidisciplinary Treatment Team.
In essence, the treatment plan serves as an organizational tool whereby the care rendered each patient is designed, implemented, assessed and updated in an orderly and clinically sound manner.
PROCEDURE:
1. Within eight hours of admission, the R.N. will initiate the treatment plan. This initial plan shall include high risk and critical medical problems and appropriate physician and nursing interventions as determined by the initial assessments, the Physicians's Treatment Plan, and the physician's orders.
3. The treatment plan shall contain specific interventions that relate to goals, are written in behavioral and measurable terms, and include expected achievement dates as well as person responsible for implementation. Development of the treatment plan will take into consideration patient care standards and program/unit or departmental policies as they relate to the individual patient.
5. The treatment plan shall include referral for needed services for the individual patient not provided directly by the hospital program.
10. The Treatment Plan shall be reviewed and updated as frequently as clinically indicated by the patient's anticipated length of stay and treatment issues;"

b) Review of the medical records for the 8 sample patients (#10, #11, #13, #14, #15, #18, #19, #20) revealed that the facility failed to ensure that nursing staff developed an revised care plans for all significant patient issues, including pain management, use of respiratory support equipment, lactation support, assessment after falls and use of restraints, seclusion and emergency medications for those patients.

c) During multiple interviews during the survey, the director of nursing confirmed the findings in the records, and stated that the lack of documentation in the areas identified in the 8 sample records (#10, #11, #13, #14, #15, #18, #19, #20) did not meet the expectation outlined in the hospital policies/procedures.