HospitalInspections.org

Intakes: TN00035763

Based on policy review, medical record review and interview, it was determined the facility failed to ensure a patient's needs were being met for pain management for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Review of the facility's "PAIN MANAGEMENT" policy documented, "...OUTCOME STANDARD: The patient will have access to the most appropriate level of pain relief that may safely be provided to ensure optimal patient comfort. The health care team will institute a plan of care to reduce pain which is mutually established with the patient...It is recognized that ineffective pain management may interfere with the healing process...Patients can expect...Healthcare professionals who respond quickly to the report of pain...POLICY...Patients have the right to appropriate pain assessment and management...The health care professional will assess the patient's pain utilizing the patient's self report as the primary source of assessment...Pain will be managed to a level that is acceptable to the patient and appropriate to the plan of care...Management of Pain...Administer pharmacological agents as ordered by the physician...Evaluate the effectiveness of analgesic medication in reducing or relieving pain to a level that is acceptable to the patient within 1 hour of administration...Notify physician of ineffective pain management following administration of the analgesic prescribed...Document the following...Physician notification of ineffective pain management..."

2. Medical record review for Patient #1 documented an admission date of 1/6/15 with diagnoses of L[lumbar]4 Fracture and Pain. The "HISTORY AND PHYSICAL" dated 1/6/15 documented, "...CHIEF COMPLAINT: Back pain and left leg pain...HISTORY OF PRESENT ILLNESS...This is a 90-year-old male with a sudden onset of severe low back pain that has been difficult to get under control with pain medications...he does have an acute L4 compression fracture...Given his level of pain, I [Physician #1] am going to admit him for IV [intravenous] pain control and plan for kyphoplasty and biopsy tomorrow..." A physician's progress note dated 1/7/15 documented, "...The patient [Patient #1] is postop [postoperative] kyphoplasty L4. Still has a lot of pain..."

The care plan dated 1/6/15 documented, "...PROBLEM: COMFORT STATUS ALTERED...Outcome: Patient's pain will be diminished and/or relieved..." The Adult Admission Assessment dated 1/6/15 documented, "...Pt. Currently In Pain...Y [yes]...Current Pain Level (0 10) 10...Pain Goal: 4..." The "PCA" [patient controlled analgesia] sheet documented, "...Check every 1hr [hour] x3 then every 4 hrs...Date...1/7 [2015] ...Time ...1030 [AM]...Pain Score...9...PCA turned off settings lost [no further assessments or PCA doses documented on sheet]..." The "MEDICATION DISCHARGE SUMMARY" dated 1/7/15 documented, "...1508 [3:08 PM] Pre Intervention Pain Scale: 10..." There was no documentation that Patient #1's pain was reassessed or reached a acceptable level between 10:30 AM and 3:08 PM on 1/7/15.

During an interview in the conference room on 4/8/15 at 9:55 AM, the 6th Floor Clinical Director stated nurses were to document pain assessment each shift and document the reassessment after any pain medication was given. When asked about the timeframe for these reassessments, the 6th Floor Clinical Director stated, "...30 minutes after IV [pain medication]...1 hour after PO [oral medication]..." The 6th Floor Clinical Director confirmed nurses were to document a reassessment of a patient's pain after pain medication and notify the physician if the patient did not reach an acceptable level of pain relief.

During a phone interview on 4/8/15 at 12:15 PM, when asked what she would do if a patient did not achieve acceptable pain relief after receiving pain medication, Nurse #1 stated, "...call the doctor...get something stronger..." When asked if she would document that, Nurse #1 stated, "...I would hope that I would..."