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Based on policy and procedure review, medical record review and staff interview, nursing staff failed to reassess pain per policy and with each new complaint of pain for 1 record (Patient # 4) and failed to check epidural levels per hospital policy for 2 of 10 records (Patients #4 and #2) reviewed.

The findings include:

Review of "...Pain Management" policy, dated 09/14/2015, revealed "...All patients will be assessed for pain.... throughout the course of treatment utilizing an appropriate pain scale (0-10 scale) with the electronic Health Record....Pain assessment before the administration of medication will include a measure of pain intensity and quality including pain character....frequency, location, and duration and will be documented in electronic health record. Pain reassessments will include the measure of pain only. Pain is assessed with each nursing assessment, within one hour of pain intervention, care transferred from one setting or provider to another, and at other regular intervals... ." Review did not reveal a policy or procedural statement specific to laboring patients.

Review of the policy "...Epidural Anesthesia in Labor & Delivery", dated 10/31/2016, revealed "...Requirements after a Labor Epidural are placed:....7. The epidural level should be assessed and documented every 2 hours. ..."

1. Medical record review, on 01/18/2017, of Patient # 4 revealed the patient was admitted on 11/10/2016 for induction of labor. At 0850, pain assessment revealed Patient # 4 denied pain. At 1515, record review revealed Patient # 4 requested pain relief and was ready for an epidural, but did not reveal a pain score to measure the intensity of pain. At 1600, record review revealed Patient # 4 was positioned for the epidural, at 1615 epidural medications were administered, and at 1640 a pain score of 3 (on a scale of 0-10, with 10 being the worst pain) was documented. On 11/11/2016 at 0000, record review revealed Patient #4 was requesting pain relief, but did not reveal a numerical pain score. At 0030, review revealed the epidural level was documented as T11 (11th thoracic vertebra). Review revealed the 0030 epidural level was the only nursing notation of level during the epidural (12 plus hours). Further review revealed additional epidural medications administered at 0043, and at 0130 and 0330 flowsheet documentation revealed the patient denied pain. Review of the flowsheet did not reveal further notation of nursing pain reassessments prior to delivery. Review of physician progress note, at 0435, revealed "...Contractions are very painful. ..." Record review revealed Patient #4 received spinal anesthesia followed by general anesthesia prior to cesarean section 11/11/2016 at 0533.


Interview with Certified Nurse Midwife (CNM) #1, on 01/19/2017 at 1130, revealed the CNM recalled the patient. Interview revealed there were periods where the epidural wasn't working and the patient was very uncomfortable.


Interview with MD #1, on 01/19/2017 at 1210, revealed Patient # 4 was in significant pain at the time of decision for cesarean section.


Interview with Registered Nurse (RN) #1, on 01/19/2017 at 1255 revealed RN #1 remembered Patient #4. RN # 1 stated the patient was very uncomfortable at times, the epidural stopped working. Interview revealed the anesthesiologist came up, more epidural medication was given, which worked for a time, but RN #1 believed it stopped working again. RN # 1 stated they did the spinal when the patient went to surgery because of it. Interview revealed RN # 1 did not assess the epidural level every two hours or thoroughly document pain reassessments. Interview revealed RN # 1 always checks the epidural level within one hour of an epidural but was not aware she needed to check it every two hours. Interview confirmed policy was not followed.


Interview with RN # 2, on 01/19/2017 around 1315, revealed RN # 2 did not check the epidural level on Patient # 4 every two hours. Interview confirmed policy was not followed.





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2. Medical record review, on 01/18/2017, of Patient # 2 revealed the patient was admitted on 11/16/2016 for induction of labor. Review revealed Patient #2 received an epidural for pain management on 11/17/2016 at 1805. Review revealed no documentation of any epidural level assessments.

Interview with the Nurse Manager on 01/19/2017 at 1030 revealed there were no epidural level assessments for Patient #2 documented. Interview revealed epidural level assessments are required to be documented every 2 hours, and hospital policy was not followed.

Based on medical record review, and patient and staff interview, facility staff failed to ensure medical records contained informed consent forms for procedures performed on 2 of 10 patients (Patients #2 and #4).

The findings include:

1. Medical record review, on 01/18/2017, of Patient #2 revealed the patient was admitted for induction of labor on 11/16/2016 and required a cesarean section delivery. Review of a Labor Note, written by Medical Doctor (MD) #2 on 11/18/2016 at 0515, revealed, "...Assessment & (and) Plan: 1. Labor Management... Recommend proceeding with c/s (cesarean section). Risks of surgery including bleeding, infection, injury to bladder, bowel, ureters, DVT/PE (Deep Vein Thrombosis/Pulmonary Embolus) were reviewed and informed consent was obtained..." Review revealed the c/s was performed on 11/18/2016 at 0602. Review failed to reveal the consent form in the medical record.

Interview with Administrative Staff #1 revealed hospital policy does not dictate how or where informed consents should appear in the medical record. Interview revealed the consent form for the c/s could not be located. Interview revealed the facility scans written documents into the facility's electronic medical record documentation system, and missing documents have been an issue. Interview revealed "there is room for improvement."



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2. Medical record review, on 01/18/2017, of Patient # 4 revealed the patient was admitted for induction of labor on 11/10/2016 and had an epidural inserted for pain relief at 1615. Record review revealed documentation of informed consent being obtained by anesthesia and nursing, but failed to reveal the consent form in the medical record.

Interview with Administrative Staff # 1, on 01/19/2017, revealed the consent form for the epidural was not in the medical record and could not be located.

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