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Based on record review, staff interview, and review of facility policy and procedures, it was determined the Registered Nurse (RN) failed to supervise and evaluate the nursing care for two (#2, #3) of three patients sampled related to pain management and care of the nasogastric tube. This practice does not ensure patient goals are met.

Findings include:

1. Review of patient #3's RN admission assessment dated 4/6/10 revealed the patient had generalized pain. On 4/08/10 at 7:15 p.m. the patient was assessed to have a pain level of 7 on a scale of 1 to 10 with 10 being the worst possible pain. The patient was medicated for pain at 7:16 p.m. There was no documentation of the patient being reassessed for the effectiveness of the pain medication. On 4/08/10 at 11:32 p.m. the patient was assessed to have a pain level of 10 and was medicated. There was no documentation of the patient being reassessed. On 4/11/10 at 7:35 a.m. the patient was assessed to have a pain level of 8 and was medicated. There was no documentation of the patient being reassessed. On 4/11/10 at 6:00 p.m. the patient was assessed to have a pain level of 6 on a scale of 1 to 10 and was medicated. There was no documentation of the patient being reassessed for the effectiveness of the pain medication.

Review of the facility's policy, "Pain Management", effective 1/2006, revealed the patient's response to pain measures will be reassessed after treatment and documented. Interview with the Unit Manager on 4/13/10 at approximately 2:45 p.m. confirmed the findings and that the patient's response to the pain medication should be documented for effectiveness.

2. Review of patient #2's medical record revealed the patient was admitted on 2/04/10 for surgery. Review of the physician orders and nursing documentation revealed a PCA (Patient Controlled Analgesia) pain pump was initiated on 2/04/10 at 7:46 p.m. Review of the facility's procedure for IV (intravenous) PCA assessment frequency revealed the patient will be assessed every hour x 4 after initiation, then every four hours until the PCA is discontinued. Review of the pain infusion pump flow sheet revealed the patient was not assessed until 4/05/10 at 1:30 a.m., which was five hours and forty five minutes later. Interview on 4/13/10 at 2:10 p.m. with the Unit Director confirmed there was no documentation for every hour x 4 as required by facility procedure.

3. Patient #2's physician orders on 4/07/10 revealed an order to irrigate the NGT (nasogastric tube) with 60 ml (milliliters) of Normal Saline solution every shift. Review of the nursing and input and output documentation revealed no evidence that the NGT was irrigated according to physician orders. Interview on 4/13/10 at 2:15 p.m. with the Unit Director confirmed there was no documentation of the NGT irrigation.

Based on record review and staff interview, it was determined the facility failed to ensure the nursing staff kept the care plan current by ongoing assessments of the patient's needs for 1 (#3) of 3 patients sampled. This practice does not ensure all nursing measures are implemented.

Findings include:

Review of patient #3's Registered Nurse admission assessment dated 4/6/10 noted the patient had generalized pain and was being medicated with pain medication. Review of the patient's plan of care revealed nursing had not identified pain/comfort on the problem list as of the date of survey. Interview with the Unit Manager on 4/13/10 at approximately 2:45 p.m. confirmed pain/comfort should have been identified on the patient's plan of care.

The plan of care documentation revealed on 4/07/10 and 4/09/10 the patient's plan of care was not reviewed by nursing to confirm the patient's needs were being met and goals prioritized. Interview with the Unit Manager on 4/13/10 at approximately 2:45 p.m. confirmed the plan of care had not been addressed on 4/07/10 and 4/09/10.