HospitalInspections.org

Based on documentation review it was determined the Hospital failed to ensure the medical record was accurately written in one of one applicable medical record reviewed.

Finding included:

Review of 6/29/10 nursing documentation recorded at 5:15 AM indicated the Patient had reported level 8 pain and 10 mg of Oxycodone was administered at 3:30 AM. However medication administration documentation did not indicated Oxycodone was administered at 3:30 AM.

Based on documentation review it was determined the Hospital failed to ensure medical records consistently contained information to describe a patient's level of pain and response to pain medications in one of one applicable medical record reviewed.

Findings included:

Review of 6/22/10 nursing documentation indicated the Patient when reassessed at 6:56 PM reported his/her pain was still an 8 and 10 mg of Oxycodone was administered and 2 mg of IV Morphine was administered at 7:49 PM. Documentation did not indicate the Patient's pain level was reassessed to check on the effectiveness of the medication. Morphine was administered orally, for breakthrough pain at 9:52 PM, however documentation did not indicated the Patient's pain level pre-Morphine.

The Staff Registered Nurse (RN #1) who was assigned to provided the Patient's care between 11:00 PM on 6/22/10 and 7:00 AM on 6/23/10 was interviewed in person on 8/30/10 at 7:30 AM. RN #1 said he/she did not document his/her initial pain assessment of the Patient but the Patient must have reported pain or requested pain medication since 10 mg of Morphine was administered.

Review of 6/23/10 nursing documentation indicated 10 mg of oral Morphine was administered at 9:50 PM. Documentation did not indicate the Patient's pain level pre-Morphine.

Review of 6/28/10 nursing documentation indicated Oxycodone was administered at 12:41 PM, however documentation did not indicate the reason for the pain medication administration. . The Patient reported, at 5:31 PM, left lower extremity pain rated as a level 8, Oxycodone was administered. Documentation did not indicate how effective the medication was. Oxycodone was administered once again at 9:24 PM. Documentation did not indicate why the medication was administered or the effect the medication had on the Patient.

Review of 6/29/10 nursing documentation indicated the Patient reported, at 4:10 PM left leg pain at a level 10 and 10 mg of Oxycodone was administered. Documentation did not indicate the effectiveness of the administered medication.