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Based on policy and procedure review, medical record review, personnel file review, staff interviews, and observation, facility failed to ensure nursing staff were providing pain management to 1 out of 10 patients (Patient #4).

The findings included:

Review on 07/10/2018 of facility policies and procedures revealed a policy titled "Pain Management,," last approved 10/2017, which stated, "An initial pain assessment and ongoing pain reassessments using assessment tools specific to the patient's needs are completed with all patients ...selection of specific pharmacologic and non-pharmacologic interventions shall be based on the type of pain the patient is experiencing." Review revealed an attachment titled "Lipincott Procedures- Pain management," last revised 11/17/2017 which stated, "The patent's report of pain is the most reliable indicator of the existence of pain ...Several interventions can be used to manage pain, including analgesics, emotional support, comfort measures ..."

Review on 7/10/2018 of the closed medical record for Patient #4 revealed a 62 year old patient who presented to the emergency department on 05/17/2018 with complaints of severe abdominal pain following a 5-day history of diarrhea and vomiting. Review revealed a CT scan (an imaging scan) of the abdomen and KUB (x-ray of the kidneys, ureters, and bladder) were performed which indicated a possible bowel obstruction and acute kidney injury due to dehydration. Review revealed an NG tube (a tube placed through the nose and into the stomach) was inserted and IV (intravenous) fluids were given. Review revealed the patient was transferred to the medical-surgical unit at 0403 on 05/18/2018. Review revealed the plan of care was hydration, pain and nausea management, and decompression of the stomach. Review revealed a pain assessment on 05/18/2018 at 1350 recorded by RN #2 in which the patient stated she had a headache and her pain level was 4/10. Review of orders revealed an order for Acetaminophen every six hours as needed. Review failed to reveal that Acetaminophen was administered to the patient. Review failed to reveal any other intervention for pain ordered or given at that time. Review failed to reveal any other pain assessment or reassessment. Review revealed an order for Ketorolac (an IV pain medication) 15mg IV one time on 05/18/2018 at 1630. Review failed to reveal the Ketorolac was administered. Review revealed a physician progress note signed by MD #1 on 05/18/2018 which stated, "I saw patient walking down the hallway...she had waited 45 min for pain medication for headache ...She stated that she was upset and had been done wrong and therefore is leaving ...She left AMA [against medical advice]." Review revealed an undated and untimed AMA form signed by Patient #4 which stated, "I had waited 2 hrs [hours] for something for pain. That's why I am leaving this place." Review revealed the patient left AMA on 05/18/2018 at 1810.

Review on 07/11/2017 of the personnel file for RN #2 revealed a yearly assessment document dated 01/14/2018 which contained an assessment by the unit manager of nursing core competencies. Review revealed an outcome of "Does Not Meet Expectations" in the category "Pain Assessment and Management." Review revealed a comment in that category which stated, "Needs to work on placing goals for pain management on whiteboard as well as providing pain medication in a more timely manner." Review failed to reveal any further documentation of coaching or remediation related to the evaluation. Further review of the personnel file revealed a Corrective Counseling document dated 05/09/2018 which stated, "Reason for counseling ...failure to scan consistently >=95% of medications per pt safety guidelines/policy for admin. [administering] medications."

Request for interview on 07/10/2018 revealed that RN #2 had resigned without notice the week after she was assigned to care for Patient #4.

Interview on 07/11/2018 at 1110 with RN #4 revealed she was the director of the unit where Patient #4 was located and was the direct supervisor for RN #2. Interview revealed the delay experienced by Patient #4 in receiving pain management did not meet expectations for nursing care on the unit. Interview revealed, "The expectation is a patient in pain takes priority and if there's not a med ordered, get a hold of the doctor." Interview revealed RN #4 was aware of the issues with the care of the patient on 05/18/2018 but that she did not address the issues with RN #2. Further interview on 07/11/2018 at 1535 revealed that she was the supervisor who conducted the competency assessment found in the personnel file for RN #2. Interview revealed the outcome of "Does Not Meet Expectations" was based on information gathered from rounding on patients and conducting chart reviews. Interview revealed that RN #4 "talked to RN #2 about the importance of addressing pain in a timely fashion," but interview confirmed there was no documentation of this conversation or any further coaching or performance assessment related to timeliness of pain management.
Interview on 07/11/2018 with MD #1 revealed he was the attending physician for Patient #4. Interview revealed he specifically recalled that she had chronic pain and "she was concerned about pain, so we made a plan." Interview revealed, "She did not have her usual [pain] meds by mouth because of the NG tube." Interview confirmed that there were no orders present on her admission to the medical surgical unit that would constitute a pain management plan. Interview revealed, "Despite our conversation, we obviously didn't have a good plan in place ...I don't have documented where we have her pain well controlled."

Interview on 07/11/2018 at 0930 with RN #3 on the unit where the named patient was located revealed that the practice on the unit is to conduct an initial pain assessment to determine what level of pain is acceptable to the patient, and then try to keep the pain at or below that level. Interview revealed he had never experienced a delay in obtaining an order for pain medicine when a patient needs it. Interview revealed, "If we ask for it, we get what we need. The doctors trust us." Interview revealed the turnaround time from asking the provider to order a medication to the medication being available to the patient is usually less than ten minutes.

Observation on 07/11/2018 at 0930 on the unit where the named patient was located revealed the facility pharmacy director was available on the unit for questions and for facilitation of medication availability.

NC00139734