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Based on record review and interview, it was determined the hospital did not supervise and evaluate the nursing care provided to 1 of 4 (#2) patients. The facility also failed to ensure that the nursing services provided to patients were provided by a nurse who was considered unfit to perform her duties. Failure to ensure that care and services are properly provided by staff that is capable may result in unnecessary suffering by the patient.

Findings:

1. A review of the medical record for Patient #2 revealed an order for pain medication: 2 mg Hydromorphone (Dilaudid) Q (every) 3 hr (hour) PRN (as needed) for the diagnosis of pain. Further review of the patient's medical record to include the pain assessment reference documents revealed the goal for pain relief is to be coded as -0- or no pain. A review of all pain medication administered from 5/13/ through 5/15/2010 was documented, with staff initial, also indicating when it was dispensed from the machine, time given and the post-administration pain scale monitoring. An interview was conducted with the Director of Pharmacy Services on 7/06/2010 during the reconciliation of the medication administration times and the pain scale monitoring. It was confirmed documentation was not consistent with the assessments documented.

According to Patient #2's record the following staff provided the following medications and assessments:
5/13/2010:
(Staff: I) 1 Hydromorphone 2 milligrams (mg) given at 1:24 AM. A Pain Scale assessment was conducted at 1:25 AM (1 minute after giving the medication) with a rating of 7.
(Staff:C) 1 Hydromorphone 2 mg dispensed at 8:14 AM and given at 8:14 AM. Pain Scale assessment completed at 8:18 AM (4 minutes after providing the medication) with a rating of 6.
(Staff: C)1 Hydromorphone 2 mg dispensed at 12:38 PM, given at 1:14 PM (36 minutes after dispensing). Pain Scale assessment conducted at 2:09 PM (55 minutes after it was given) with a pain rating of 8.
(Staff: D)1 Hydromorphone 2 mg given at 9:41 PM. A Pain Scale assessment conducted at 9:45 PM (4 minutes after providing) with a scale of 7.

5/14/10 -- (Hydrom = Hydromorphone)
(Staff: C)1 Hydrom 2 mg dispensed at 8:25 AM and given 8:34 AM (9 minutes later). Pain Scale assessment was Not Listed.
(Staff: C)1 Hydrom 2 mg dispensed at 11:05 AM and given 11:29 AM (25 minutes after dispensing). Pain Scale assessment conducted at 1:04 PM (an hour and 5 minutes after providing the medication to patient #2), with a pain scale of an 8.
(Staff: V)1 Hydrom 2 mg dispensed at 2:03 PM, given at 2:07 PM. A Pain Scale assessment was Not Listed.
(Staff: D)1 Hydrom 2 mg 3:59 AM dispensed and given 4:05 AM. A Pain Scale assessment at 4:15 AM (10 minutes after providing medication) with a score of 5.
(Staff: V)1 Hydrom 2 mg 5:39 PM dispensed and given at 5:39 PM. A Pain Scale assessment was Not Listed.

Pain Scale readings do not always correspond to administration record
-- Pain Scale at 7:30 PM and 7:55 PM are both recorded at 0. Even though noted as pain score of 0 -- medication was noted as administered;

5/15/10
(Staff: D)1 Hydrom 2 mg 12:52 PM dispensed and given 12:53 PM. A Pain Scale assessment was conducted at 1:55 AM (more than 12 hours later) with a scale of 5.
(Staff: D)1 Hydrom 2 mg 4:10 AM dispensed and given 4:10 AM. A Pain Scale assessment was completed at 5:41 AM (one hour and 31 minutes after giving it) with a rating of 0.
No intervening pain scale rating is documented - it appears pain medication was given without the complaint of pain
(Staff:V)1 Hydrom 2 mg 7:37 AM dispensed and given at 7:37 AM. Pain Scale at 7:41 AM - 0
(Staff: V)1 Hydrom 2 mg 11:28 AM dispensed and given at 11:30 AM. Pain Scale 11:29 AM ( a minute before giving the medication) with a rate of 7.


Review of the policy and procedure for Pain Management, Assessment, Reassessment and Documentation #PE007.610 revealed: "The patient has the right to appropriate assessment and management of pain. This includes: Initial assessment and regular reassessment of pain. Reassessment if pain occurs after each administration. Reassess pain relief 1 hour after PO (by mouth) administration. Education of relevant health care providers in pain assessment and management." The Reassessment should: "be completed after each intervention; at time intervals 1 hour after oral preparations. Include reassessment and documentation of: pain relief obtained; pain scale score; if not effective, further action taken."

An interview was conducted with the Risk Manager on 7/06/2010 at 12:10 PM, confirming staff document by exception, and that through review of the nursing notes and other medical record documentation, there was no indication as to the consistent monitoring or documentation regarding the effectiveness of the Hydromorphone (Dilaudid) being administered to patient #2.

2. An interview was conducted with the newly appointed Unit Manager, Director of Risk Management, Human Resources Director on 7/06/2010 beginning at 11:30 AM, and later in the day with the Director of Quality Management. It was reported the Registered Nurse (#1) had been observed at the end of the work shift on 5/06/2010 by the Supervisory Staff. The RN's behavior included: "being very groggy, slurring her words and unable to stay awake. While being asked questions, the RN was closing her eyes; had difficulty maintaining an upright position and while going to a cab, was unable to walk in a straight line and had a difficult time speaking effectively." It was confirmed with a validation of the Kronos time keeping system printout, the RN had worked that evening/night shift and was leaving the hospital when observed. The Administrative staff was asked if the employee had been identified as "under the influence" or if a urine or blood screen had been conducted as a result of the observations. It was confirmed by the Unit Manager and Director of Human Resources that it was believed the employee was a victim of spousal abuse and was sleep-deprived. With that justification, it was believed that a toxicity screen was not necessary.

Subsequent to these events, the RN was suspended and returned to work on 5/13/2010. The staff had identified the RN as being, "unfit for work," as the justification for the suspension. Review of the employee information revealed, "RN, during and following her/his shift, appeared unfit for duty. She was observed at the nursing station having an inordinate amount of difficulty staying awake. According to several witnesses, her speech was slurred and gait was uncoordinated. According to accounts from the nursing supervisor, [Vice President] of Human Resources and PCU night shift unit staff, the RN's behavior caused great concern for the safety of the staff and patients on the unit. Documentation of the witnessed behaviors is attached to this document."

The Human Resources Policy #HR705.916 indicates, "Circumstances Under Which a Drug Test May Be Administered: Where there is reason to believe, in the opinion of the Hospital, that an associate is impaired as demonstrated by observance of behavior, performance or action while on the Hospital property or during working hours, or that an associate has reported to work with a measurable quantity of intoxicants, drugs or narcotics in blood or urine." As noted, there was no drug test administered.

A review of the medical record for Patient #2 revealed the patient had an order for 2 mg Hydromorphone (Dilaudid) Q (every) 3 hr PRN (as needed) for pain.

An interview was conducted with Patient #2 and spouse at 1:58 PM. The patient stated the care provided her/him by a staff Registered Nurse during the hospitalization of 5/12/2010 through 5/15/2010 was extremely inappropriate, leaving the patient in what was described as "constant and at times excruciating pain." Patient #2 explained that the conduct displayed by the Registered Nurse was that of one who was "incoherent, slurring words, leaning against a wall falling asleep, attempting to administer the incorrect medication to the patient, and one who appeared to be under the influence." It was reported by the patient and spouse that on more than one occasion, the RN attempted to administer a medication other than the Hydromorphone (Dilaudid). The patient refused to take the medication being offered by the RN. At that time, it was reported the RN would leave the room and reenter with the correct medication. It was reported the patient and spouse had reported this to the Nursing Supervisor, as well as other nursing staff. It was reported the Nursing Supervisor told the patient and spouse they were aware of the problem (regarding the RN), and that the RN would not be returning.

The RN returned to work on 5/13/2010. Once again, the RN was unable to stay awake, was slurring words, and incoherent.

Reports documented by hospital staff were provided and revealed an alleged incident occurring approximately 3 weeks prior to this incident, regarding medication being removed from the medication unit by the RN. It was reported the RN had requested the assistance of another staff member in this action, however the staff member, feeling very uneasy about the request, had refused.

Further review of the RN's time validation revealed a work schedule which included the dates of 5/01, 03, 04, 05 and 06. After suspension, the employee was returned to work completing a full shift on 5/13/2010 and a 5-hour shift on 5/14/2010 when the RN was terminated.