HospitalInspections.org

Based on medical record review, interview, and review of policy and procedures, it was determined the facility failed to ensure a Registered Nurse supervised and evaluated the nursing care for two (#1, #2) of three patients sampled related to pain management. This practice does not ensure patient goals are achieved.

Findings include:

1. Patient #1 post operative physician orders dated 3/02/10 at 1:40 p.m. instructed for a continuous intravenous pain medication drip. Review of the analgesia medication record revealed the pain medication drip was initiated on 3/02/10 at 2:00 p.m. Review of the facility's policy, "Care of the Pediatric Patient Needing Pain Management", states the patient's pain and sedation score will be assessed every four hours and with dose change. Review of the analgesia medication record and nursing documentation revealed the patient was not assessed for pain or sedation score according to facility's policy. Interview on 4/15/10 at 2:00 p.m. with the Safety/Regulatory Manager confirmed the above findings.

2. Patient #2's post operative physician orders dated 3/11/10 at 12:00 p.m. instructed for Morphine Sulfate (pain medication) every 1-2 hours as needed for pain. Review of the MAR (Medication Administration Record) revealed on 3/11/10 at 7:50 p.m. the patient was medicated for pain. Review of the facility's policy, "Care of the Pediatric Patient Needing Pain Management", states the patient will be reassessed within 60 minutes after a pain intervention. Review of the MAR and nursing documentation revealed no documentation the patient was reassessed after the pain medication was administered. Review of the MAR revealed the patient was medicated for pain on the following dates and times.
On 3/11/10 at 11:30 p.m. pain medication was provided.
On 3/13/10 at 10:00 a.m., 6:30 p.m., 8:00 p.m., 9:30 p.m., and 11:30 p.m. the child was medicated for pain. On 3/14/10 at 4:30 a.m., 7:30 a.m., 11:45 a.m., and 3:00 p.m. pain medication was administered. Review of the MAR and nursing documentation revealed the patient was not reassessed within 60 minutes of a pain intervention as required.

Interview on 4/15/10 at 2:00 p.m. with the Safety/Regulatory Manager confirmed the above findings.