HospitalInspections.org

Based on documentation in three of four medical records reviewed (#s 1, 2, and 3) and the review of hospital policy and procedure it was determined that the hospital failed to ensure that patients' pain needs were managed in accordance with appropriate assessment, physician orders, and its own policies. Findings include:

The hospital policy and procedure titled Adult Pain Assessment and Management Program was reviewed. Steps or Key points included "...the patient's self-report of pain is accepted as the most reliable marker of the presence and extent of pain...Assess pain on admission to the hospital and a minimum of twice daily...In collaboration with the patient, establish a patient comfort goal on admit and reassess every morning...If established patient-specific pain management outcomes are not achieved, this will elicit review and modification of the pain management plan..." The policy requires that physicians and nurses are the primary implementers of the "pain management plan"; that pain assessment will be conducted using a pain scale for adults of 1 to 10 with 10 reflecting the greatest pain; and that assessment, treatment and reassessment of pain will be documented.

1. Patient #1 had a diagnosis of spinal stenosis of lumbar region and was admitted on 10/1/09 for laminectomy and lumbar fusion. The surgery was performed on 10/1/09 and the patient was subsequently transferred to an inpatient room. After the surgery the patient experienced drops in blood pressure which resolved midway through 10/2/09. The patient was discharged to home on 10/6/09.

On 10/1/09 at 1820 the physician ordered Dilaudid 1 - 2 mg IV every 1 hour prn (as needed) pain and Dilaudid 2 mg tabs 1 - 2 tabs (2 - 4 mg) po (by mouth) every 4 hours prn pain.
On 10/2/09 at 0700 the physician ordered the anti-inflammatory Toradol 15 - 30 mg IV every 8 hours prn.
On 10/2/09 at 1120 the physician increased the frequency of the Toradol to every 6 hours prn and decreased the dosage of the IV Dilaudid to 0.5 - 1.5 mg every 1 hour prn.
On 10/3/09 at 1100 the physician ordered OxyContin 20 mg po twice daily.

The Pain Assessment Flowsheet (PAF) contained ongoing documentation of the patient's pain comfort goal and his/her verbalized pain score. The review of the PAF, the nursing progress notes, the nursing shift assessments, and the medication administration record (MAR) reflected that the dosages of the prn medications administered were not consistent with the patient's pain scores.

On 10/2/09 at 0903 the patient's pain score was 10 and 30 mg of Toradol was given. On 10/4/09 at 0829 the pain score was 10 yet only 15 mg of Toradol was given.
On 10/2/09 at 1727 the pain score was 8 and 15 mg of Toradol was given. However, on 10/3/09 at 0252 the pain score was 8 and 30 mg of Toradol was given.
On 10/3 at 0115, 10/4 at 1234, and 10/5/09 at 1046 the pain score was 8. The patient was given 4 mg of po Dilaudid on 10/3 and 10/5, yet was given only 2 mg on 10/4.
On 10/5 at 2145 and 10/6/09 at 0608 the pain score was 10 yet only 2 mg of po Dilaudid was given.
On 10/5 at 1713, 10/6 at 0958, and 10/6/09 at 1354 there was no pain score documented however the patient was given po Dilaudid 2 mg, 4 mg, and 2 mg respectively.

Dilaudid po was administered a total of 16 times. 4 mg was given on three of those occasions for pain scores of 8 and with no score. While on 13 occasions 2 mg was given with no score on 2 occasions, a score of 3 on one occasion, a score of 6 on one occasion, a score of 7 on 5 occasions, a score of 8 on one occasion, a score of 9 on one occasion, and a score of 10 on 2 occasions.

Effective 10/1/09 at 1927 physician's orders also included a skeletal muscle relaxant Soma 350 mg tablet every 6 hours prn, an adjunctive treatment for acute, painful musculoskeletal conditions. The MAR reflected that this was administered 4 times thereafter; 2 times with Dilaudid for pain scores of 7 and 10, once with no Dilaudid and a pain score of 9, and once with no Dilaudid and no pain score.

The PAF reflected that the patient's comfort goal ranged between 2 and 3 throughout the hospitalization. It further reflected that the patient's verbalized pain score was documented 60 times during the hospitalization. On only 11 of those times was the score 3 or below.

On 10/4/09 at 1619 a nursing progress note reflected that "pain management" was discussed with the patient. However, there was no documentation of what that discussion consisted of. On 10/6/09 at 1009 and 1039, the day of discharge, nursing progress notes reflected the the charge RN and the patient talked "about pain management schedule", and although there was no pain score documented the patient was medicated with 4 mg Dilaudid and stated "I think that will work better".

The physician's hospital Discharge Summary dictated on 10/16/09 indicated that "The patient...with significant facet disease and foraminal stenosis who has been plagued with back and leg pain and has exhausted conservative measures...the combination of pain medications was affecting...blood pressure...having fairly low blood pressure...was having a lot of pain and a significant amount of pain medications were given...the pain issues continued and on 10/3/09, we had to add OxyContin to...regimen...the patient mentioned at different times some element of frustration with the timing of...pain medication..."

There was no evidence of a pain management plan developed in conjunction with the patient, beyond physician orders, which ensured that the patient would receive pain medication intervention consistent with his/her pain score. Further, there was no evidence that the patient's lack of progress towards his/her comfort goal was evaluated and assessed, to include identification of the inconsistencies in the dosage of medication administered.

2. Patient #2 had a diagnosis of displacement of lumbar intervertebral disc without myelopathy and was admitted on 10/5/09 for lumbar decompression. The surgery was performed on 10/5/09 and the patient was subsequently transferred to an inpatient room. The patient was discharged to home on 10/8/09.

On 10/5/09 at 1800 Adult Standard Pain Orders were initiated by the physician. Those orders were:
Group 2a - acetaminophen 650 mg orally every 4 hours as needed for mild pain (1-3/10).
Group 3 - oxycodone 5 mg/acetaminophen 325 mg (aka Percocet) 1-2 tablets (2 - 4 mg) orally every 4 hours as needed for moderate pain (4-6/10).
Group 4 - hydromorphone (aka Dilaudid) 0.5-1.5 mg IV every 2 hours as needed for severe pain (7-10/10).
The Standard Orders form also indicated that "May use selected drug from lower group for higher pain level per patient preference/response."

The review of the PAF, the nursing progress notes, the nursing shift assessments, and the MAR reflected that the prn medications administered were not consistent with the patient's pain scores.

Between 10/5 and 10/8/09 the patient received 8 doses of Percocet 4 mg for pain. On four of those occasions the patient's pain score was documented as 5 or 6, consistent with the administration of the Percocet. However, on two of those occasions, 10/6 at 0303 and 10/8/09 at 0505, the pain score was 7. The physician's Standard Orders indicated that Dilaudid IV be given for a pain score of 7. Although there was no evidence on the PAF or in nursing progress notes to reflect assessment of the possible use of medication from the lower group, including collaboration with the patient, the MAR reflected that the patient was given Percocet, from the lower group.

On two other occasions, 10/7/09 at 0654 and 1224, there was no pain score documented and no corresponding assessment around the administration of Percocet at those times.

3. Patient #3 had a diagnosis of spinal stenosis of lumbar region and was admitted on 10/13/09 for dorsal and lumbar fusion. The surgery was performed on 10/13/09 and the patient was subsequently transferred to an inpatient room. The patient was discharged to home on 10/16/09.

On 10/13/09 at 1300 Adult Standard Pain Orders were initiated by the physician. Those orders were:
Group 2a - acetaminophen 650 mg orally every 4 hours as needed for mild pain (1-3/10).
Group 3 - oxycodone 5 mg/acetaminophen 325 mg (aka Percocet) 1-2 tablets (2 - 4 mg) orally every 4 hours as needed for moderate pain (4-6/10).
Group 4 - hydromorphone (aka Dilaudid) 0.5-1.5 mg IV every 2 hours as needed for severe pain (7-10/10).
The Standard Orders form also indicated that "May use selected drug from lower group for higher pain level per patient preference/response."

The review of the PAF, the nursing progress notes, the nursing shift assessments, and the MAR reflected that the prn pain medications administered were not consistent with the patient's pain scores.

On 10/13/09 at 1643 and 1951 the PAF reflected that the patient's pain scores were 6 on those occasions, indicating the use of Percocet. However, the MAR reflected that Dilaudid IV from the higher group was given. Additionally, on 10/14 at 2029 and 10/15/09 at 1016 the PAF reflected that the pain scores were 2 and 3 respectively, indicating the use of acetaminophen. However, the MAR reflected that Percocet from the higher group was given. Although there was no evidence on the PAF or in nursing progress notes to reflect assessment of the possible use of medications from the higher groups, including discussion with the physician, the MAR reflected that the patient was given medications from the higher groups on those occasions.

On 10/14/09 at 1030 the pain score was 7, indicating the use of Dilaudid IV. Although there was no evidence on the PAF or in nursing progress notes to reflect assessment of the possible use of medication from the lower group, including collaboration with the patient, the MAR reflected that the patient was given Percocet, from the lower group.

On two other occasions, 10/14 at 0300 and 10/16/09 at 1849, there was no pain score documented and no corresponding assessment around the administration of Percocet at those times.

Effective 10/13/09 at 1422 physician's orders also included the skeletal muscle relaxant Soma 350 mg tablet every 6 hours prn. The MAR reflected that this was administered 4 times thereafter; 3 times with Percocet for pain scores of 2 and 5, and once with no Percocet and no pain score.

On 1/8/2010 these issues were discussed with the Performance Improvement Manager and the Nurse Manager of the NeuroTrauma Unit.