HospitalInspections.org

I. Based on document review and staff interview, the acute care hospital failed to:

1. Ensure the nursing staff followed the hospital's policies and procedures for pain assessment and interventions for 2 of 14 sampled patients (Patients #1 and #2). Please refer to A-0395.

2. Ensure the nursing staff followed the hospital's Nursing Practice Process Standards for repositioning and range of motion for 1 of 14 sampled patients (Patient #1). Please refer to A-0395.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to ensure the nursing staff safely provided nursing care to patients.

II. During the investigation of incident 71218 -I the on-site survey team identified an Immediate Jeopardy (IJ) situation (a crisis situation that placed the health and safety of patients at risk) related to the Condition of Participation for Nursing Services (42 CFR 482.23). The hospital staff failed to assess and implement interventions to prevent skin injury for 1 of 14 sampled patients, and failed to ensure adequate pain assessments for 2 of 14 sampled patients.

On 10/ 10/17 the administrative staff received notification of the IJ. The adminstrative team took action in attempt to remove the immediacy of the situation. The Immediate Jeopardy was removed on 10/16/17 prior to completion of the onsite visit.

Based on medical record review, observation, interviews and facility policies the facility failed to:

a. Implement interventions to ensure patients admitted did not acquire skin injury for 1 of 14 sampled patient (Patient #1).

b. Ensure nursing staff assessed pain and implemented appropriate interventions for 2 of 14 sampled patients (Patient #1 and #2).

Findings include:

1. Review of the hospital policy Basic Care Management Guideline: Adult and Geriatric patients, revised 8/17, directed staff to complete a (Head to Toe) assessment of systems (every 8 hours; every 4 hours x 48 hours following transfer from Critical Care and with status changes. Nursing staff are to assess circulation and skin condition with each assessment. The policy directed staff members to round on each patient at least hourly to address ... positioning ... identify the level of risk and initiate appropriate interventions if the Braden Score (standardized assessment tool used to determine a patient's risk of developing a pressure ulcer) is 18 or less. Initiate Impaired Skin Management Standard if skin breakdown occurs ....Elevate lower legs on enough pillows to suspend/float heel off mattress at all times.

A Braden score evaluates risk factors but not limited to, mobility, sensory, moisture, and activity. A Braden score of 15-18 indicates a patient is a mild risk, 13 - 14 indicates moderate risk, 10 - 12 indicates high risk, and a score of 9 indicates very high risk to develop a pressure ulcer.

During an interview on 10/4/17 at 9:04 AM the Associate Chief Nursing Officer (ACNO) stated nursing staff are expected to complete a (head to toe) assessment of systems every 8 hours, and every 4 hours with a status change. The assessment policy pertains to all medical floors in the acute care hospital with the exception of critical care. (A nursing assessment of systems includes a nursing assessment of all body systems such as skin, heart, lungs, stomach, etc.)

2. Investigation of the hospital reported incident, date of occurrence 9/24/17, regarding nursing care for Patient #1 revealed the following:

a. Patient #1, an 87 year old, transferred to the acute care hospital on 9/16/17 with a chief complaint of abdominal pain with an anticipated surgical procedure related to possible gallstones.

The History and Physical (H&P) dated 9/17/17 revealed the following:

-Patient #1 exhibited some memory issues/confusion and reported "awful" pain all over. The physician's assessment revealed no edema (swelling) noted to the patient's lower extremities.

-Past medical history included atrial fibrillation (irregular heart rhythm) with medication to prevent blood clots, congestive heart failure (CHF), and coronary artery disease (CAD.)

-Admission physician orders directed staff to weigh Patient #1 each day and apply bilateral (both legs) thigh high SCDs (sequential compression device) when in bed. SCDs are devices that when applied, provide compression to lower extremities in attempt to prevent formation of blood clots.

Admission nursing assessments dated 9/16/17 revealed Patient #1 scored 13 on the Braden skin assessment tool and listed a moderate risk to develop pressure ulcers. Risk factors identified included: bedfast, very limited mobility, probably inadequate nutrition, potential problem with friction and sheer, slightly limited sensory and occasionally moist.

Nursing staff identified Patient #1 as a medium fall risk and initiated VPO (virtual patient observation) as a fall intervention. Patients on virtual patient observation have a video monitoring system in their hospital room. Hospital staff members (VPO staff) continually observe patients from a monitor in a different room. When the patient exhibits a safety risk, VPO staff notify nursing staff by hospital voice system or an overhead page to the nursing staff.

b. During an interview on 10/3/17 at 11:00 AM, Patient #1 complained of bilateral foot pain and wanted no one to touch them. Patient #1 reported the wounds happened one night, he/she slept in a chair because he/she did not have a bed to sleep in. The family was pretty upset. Patient #1 was alert and oriented to name, date and location. Observation of the patient's lower extremities revealed the patient's bilateral lower extremities wrapped with Kerlix (Type of bandage). A note written on the dressing directed staff to only move by heels and change the dressing every other day.

c. During an interview on 10/3/17 at 4:00 PM, Patient #1's family members reported observing staff members transfer Patient #1 into the chair on the morning of Saturday, 9/23/17. The family members did not identify skin injuries on 9/23/17.

On Sunday morning, 9/24/17, family returned to the hospital and discovered large blisters on Patient #1's lower extremities. The family described the blisters as sandwich baggies stuffed full of sloshing water. One blister was described as the size of a football.

The family reported the skin concerns to the nurse supervisor who identified never seeing anything like that before. Patient #1 was almost in tears because the wounds burn from the treatment. Family members then requested staff members provide pain medication prior to tomorrow's planned dressing change.

While the family was interviewed on 10/3/17 around 4:00 p.m. Patient #1 reported that a woman comes in every day and puts iodine on the sores and it hurts a lot.

Patient #1's family believes the staff members should have helped and explained why the Patient needed to sleep in bed. Family members identified the staff failed to apply support hose during the hospitalization, as worn at home for edema. Patient #1 woke up during the family interview and reported his/her feet are sore because she puts iodine on them and it hurts.

Interview with Patient #1 on 10/3/17 at 4:00 p.m. revealed the family identified Patient #1 slept up in a chair one night while in the hospital. Patient #1 reported confusion at times and that both feet are sore from being up in the chair all night.

According to Patient #1's family members, at the time of admission Patient #1 walked into the hospital, now can't walk. Patient #1's family members requested the nursing staff provide pain medication prior to the dressing change on 10/4/17.

d. During an interview on 10/2/17 at 2:14 PM, Nurse Director AA reported on 9/24/17 she received notification of Patient #1's skin injuries and the family concerns. According to Nurse Director AA, family members reported the blisters developed on Patient #1 overnight from 9/23/17 - 9/24/17. According to Nurse Director AA family informed her that Patient #1 sat in a chair from approximately 7:00 AM on 9/23/17 until the family arrived the morning of 9/24/17. Family believed this caused the blisters on Patient #1's lower extremities. Nurse Director AA began an investigation that included employee badge location (Hill Rom) documentation.

Nurse Director AA's investigation confirmed the family allegation. The investigation revealed two Patient Care Technicians (PCT N and PCT K) transferred Patient #1 to a chair on 9/23/17 around 7:00 AM - 7:30 AM. Nurse F transferred the patient back to bed on 9/24/17 at approximately 1:00 - 1: 30 AM. and Nurse F observed blisters to the patient's lower extremities at that time. The investigation revealed Nursing staff documentation identified no skin integrity concerns on 9/23/17 for Patient #1.

Nurse Director AA reported nursing staff members wear a type of badge called Hill Rom, that allows the hospital to identify the location and time staff members enter or leave patient rooms. Nurse Director AA's investigation revealed there is no badge information for Nurse F because Nurse F is a contract nurse hired through a nursing agency as a temporarily assigned nurse.

e. According to the Hill-Rom badge locator documentation, on 9/23/17 from 8:43 AM through 8:48 AM PCT N and PCT K entered Patient #1's room. This was the only documented time the PCTs are identified in Patient #1's room per Hill-Rom badge locater documentation during that shift.

Review of Hill Rom documentation revealed a variety of nursing staff entered and exited Patient #1's room 35 times on 9/23/17 from 8:50 AM through 9/24/17 at 1:30 AM.

According to Nurse Director AA the badge documentation does not include information from RN F, PCT B, and PCT D, all assigned to provide nursing care to Patient #1 on 9/23/17 from 7:00 PM through 9/24/17 at 7:00 AM.

f. Review of the VPO video log documentation revealed on 9/23/17 at 8:30 AM Staff O, video monitor, observed staff transfer Patient #1 into the chair. Staff O documented Patient #1 remained in the chair from 9/23/17 at 8:30 AM until his shift ended at 7:00 PM, a total of 10.5 hours.

The 9/23/17 video log failed to include documentation that indicated nursing staff provided transfer assistance or bathing assistance during the 10.5 hours observed by Staff O.

Review of video log documentation revealed on 9/23/17 at 7:00 PM Staff E, video monitor, observed Patient #1 in the chair from 7:00 PM until 9/24/17 at 1:30 AM, a total of 6.5 hours.

According to the VPO video log documentation, video monitor staff observed Patient #1 in a chair for a cumulative total of 17 hours with no documentation of transfer or bathing assistance from hospital staff members.

g. During an interview on 10/2/17 at 3:31 PM, RN A revealed 9/23/17 that was the third day she provided nursing care to Patient #1 and described Patient #1 as weak. RN A identified Patient #1 as alert, but frequently required cues and reminders from staff and family members. RN A reported no observed skin concerns on 9/23/17 during her shift from 7:00 AM through 7:00 PM. According to RN A she requested staff transfer Patient #1 into the chair early in the day. RN A commented Patient #1 refused transfer assistance back to bed because (his/her) feet fall asleep and can't feel them. RN A confirmed she was in and out of Patient #1's room during the day to administer medication, draw blood and assessed Patient #1 around 7:00 AM and 3:00 PM. RN A reported she was in Patient #1's room on 9/23/17 at approximately 4:45 PM but did not observe the patient's legs. RN A was aware Patient #1 had a cardiac history. RN A failed to encourage Patient #1 to elevate the lower extremities while in the chair.

h. PCT N's interview on 10/2/17 at 7:46 PM, revealed the morning of 9/23/17 she provided nursing care to Patient #1 for four hours. Staff informed her Patient #1 required a mechanical lift or 2 staff for transfer. At approximately 7:30 AM, Patient #1 requested to sit in the chair. PCT N and PCT K transferred Patient #1 to the chair. PCT N failed to observe any skin concerns prior to the end of her shift on 9/23/17 at 11:00 AM.

i. PCT K's interview on 10/9/17 at 7:33 PM, PCT K identified she assisted PCT N in transferring Patient #1 to the chair on 9/23/17 between 7:00 AM and 11:00 AM. She could not recall a more exact time she provided transfer assistance and did not return to Patient #1's room during her shift.

j. PCT C's interview on 10/3/17 at 1:27 PM, identified she provided nursing care to Patient #1 on 9/23/17 at 11:00 AM. Patient #1 was up in the chair at the beginning of her shift. PCT C bathed Patient #1 at an unknown time, and did not observe blisters on the patient's legs. PCT C observed a red area on the patient's coccyx, but failed to notify the nurse. Patient #1 always said (he/she) was fine. At approximately 6:30 PM, PCT C emptied the patient's urinary retention bag, but did not view the patient's legs because a blanket covered the lower extremities.

k. Staff O revealed during a interview on 10/11/17 at 2:05 PM, as the video monitor staff, he monitored the video monitors on 9/23/17 from 7:00 AM through 7:00 PM. but was unable to recall specific information regarding Patient #1.

l. PCT B's interview on 10/2/17 at 3:55 PM, PCT B revealed on 9/23/17 she entered Patient #1's room to collect the dinner tray at approximately 7:00 PM and observed Patient #1 in the chair. According to PCT B, Patient #1 did not want to go to bed.

PCT B confirmed three PCTs worked until 11:00 PM. She spent a lot of time in another patient's room because of the patient's deteriorating status.

At the end of her shift at 11:00 PM on 9/23/17, all patients were assigned to 1 PCT from 11:00 PM through 9/24/17 at 7:00 AM. According to PCT B one PCT was not adequate to provide care to over 30 patients because patients are incontinent, need turned, etc.. PCT B believed the floor was also short nurses that night. Nurses have to follow a hospital staffing Matrix to determine the number of nurses and PCT staff assigned for patient care.

m. During an interview on 10/5/17 at 8:40 AM, RN F reported 9/23/17 was a busy night and short on nursing staff. RN F provided nursing care to seven patients, one of which was a new admission before midnight. One PCT provided care for approximately 35 patients. RN F provided nursing care for Patient #1 the night before and recalled the patient as extremely confused and upset. The patient's family member stayed with Patient #1.

RN F did not enter Patient #1's room at the beginning of her shift. She observed Patient #1 in the chair as she passed the room, and thought the patient seemed calmer so she let her rest. RN F commented RN A did not mention how long Patient #1 was in the chair at shift report.

According to RN F on 9/23/17 at approximately 9:00 PM, she administered Patient #1's medications and checked vital signs. She failed to complete a head to toe assessment at 9:00 PM but noted a blanket covered Patient #1's lower extremities.

On 9/23/17 at approximately 11:00 PM RN F was assigned seven patients, and midnight medication administration was late. Patient #1 remained in the chair and appeared comfortable. When RN F returned to Patient #1's room, she encouraged the patient to get into bed between 12:00 AM and 1:00 AM Patient #1 agreed. RN F noticed the blisters during the transfer process. After Patient #1 was in bed, she observed the severity of the skin issues on Patient #1's legs and reported the skin injury to the charge nurse and then notified the hospitalist (an on call Physician located in the Hospital). According to RN F the hospitalist commented the blisters are third spacing (fluid collection in low extremities) of fluid and directed staff to keep Patient #1's lower extremities elevated.

RN F reported she failed to measure the blisters, and was unsure if she documented anything on them. She did inform the day nurse about blisters in report at the end of her shift.

n. PCT D's interview on 10/2/17 at 3:31 PM PCT D revealed she provided care to Patient #1 one time from 9/23/17 at 11:00 PM through 9/24/17 at 7:00 AM. At approximately 2:00 AM she placed Patient #1 on a bedpan. PCT D observed blisters on top of each foot, and 2 blisters on the outer portion of the patient's left ankle. PCT D described the right foot blister as big as the palm of her hand. PCT D assumed RN F was aware of the blisters because RN F assisted Patient #1 from the chair into bed earlier.

According to PCT D the staffing Matrix allows 1 PCT on the overnight shift for 34 patients. She does not feel that is safe, and has informed nurses.

o. During an interview on 10/3/17 at 8:22 AM, Staff E, video monitor, was on the overnight shift 9/23/17 from 7:00 PM through 9/24/17 at 7:00 AM. She observed Patient #1 in the chair when she came on duty. Staff O, day shift video monitor, reported off to Staff E that Patient #1 was in the chair all day.

Staff E reported as a certified nursing assistant (CNA) she knew it was unusual for a patient to be in the chair all day, but was informed in her orientation not to tell PCTs what to do, so she failed to report this.

According to Staff E at 11:00 PM the floor was staffed with five nurses and one PCT for all patients. Additionally, a couple patients actively wandered on the unit.

Staff E observed RN F transfer Patient #1 to bed and documented on the VPO sheet. RN F informed Staff E that she observed four very large blisters on Patient #1's lower extremities. Staff E looked at the VPO sheet, a flow sheet used for video monitoring and documenting observations every 30 minutes. The VPO sheet revealed nursing staff assisted Patient #1 to the chair at approximately 8:00 AM on 9/23/17. Staff E reported Patient #1 sat in the chair from approximately 8:00 AM on 9/23/17 until 1:00 AM on 9/24/17 according to the VPO documentation.

p. During an interview on 10/2/17 at 2:14 PM, Nurse Director AA revealed she discovered the following information during the facility investigation:

- PCT staff reported transfer of Patient #1 to a chair at approximately 7:00 - 7:30 AM. The patient was left in a chair for approximately 18 hours.

- The patient's admission orders directed thigh high SCD's on while in bed and daily weights. Nursing staff failed to implement physician orders because they did not look at all pages of physician orders.

- On 9/23/17 there was a staffing glitch. A nurse was not scheduled for the overnight shift which left them short one nurse. Five nurses and one PCT provided all nursing care for for a total of 35 patients, which included an admission before midnight.

The hospital's unit staffing Matrix, allowed for six nurses and two PCTs for 35 patients on 9/23/17 at 11:00 PM overnight shift. Currently, there is one PCT employed for the overnight shift.

3. Observation of Patient #1's dressing change on 10/4/17 at 10:00 AM revealed Wound Ostomy Continence Nurse (WOCN) FF and RN P enter Patient #1's room. WOCN is a nurse with specialized training to perform wound care, ostomy care, and continence care. The WOCN nurse attains certification after successful completion of a competency test. Upon entry the dressing change supplies are located on the bedside table.

a. WOCN FF identified her initial assessment of the blisters occurred on Monday 9/25/17 while the patient was in bed. She neglected to take photos of Patient #1's wounds. WOCN FF reported Patient #1 complains of pain during the dressing changes and always gets pain medication prior to the dressing change.

b. On 10/4/17 at 10:15 AM RN P administered Morphine 2 milligrams (mg) for pain. Patient #1's pain was rated at a 7 out of 10 but increases usually during the dressing change.

c. WOCN FF performed the dressing change as follows on Patient #1's bilateral (both) lower extremities:

-WOCN FF donned three pairs of gloves.

-WOCN FF encouraged Patient #1 too relax as she cut gauze (Kerlix) off the left lower extremity. WOCN identified the red areas are deroofed (exposed skin) blisters covered with a layer of silicon.

-WOCN FF poured saline onto the areas covered with silicon as she pulled the silicon off the open wound. Patient #1 complained of pain during the process.

- Patient #1's groaned and winced as WOCN FF moved the patients foot up and down to remove the silicon dressing product. WOCN FF mentioned the blisters are drying up.

-WOCN FF wiped and dabbed Patient #1's foot with normal saline and 4 x 4's as Patient #1 winced in pain every time WOCN FF touched the red, open areas. Then WOCN FF discarded one pair of gloves.

-WOCN FF picked up a 4 x 4 and wiped down the leg toward the ankle. Patient #1 began to cry as WOCN FF wiped the left lower leg.

-WOCN FF then discarded the second layer of gloves, and requested RN P lift the patient's foot.

-WOCN FF placed a silicone cover to the open red area on the ankle. Patient #1 cried out and WOCN FF reported the painful part is done now.

-WOCN FF dabbed Iodine onto the left lower extremity, then wrapped the left lower extremity with Kerlix. The Iodine was not dry prior to application of the Kerlix wrap. WOCN FF informed the patient she was almost done. She directed RN P to hold the heel of Patient #1's foot as she wrapped Kerlix from the ankle down to the toes, and another roll of Kerlix from the toes up. Patient #1 winced and moaned during the application of the Kerlix.

-WOCN FF secured, dated and initialed the dressing.

-WOCN FF directed RN P to cut the Kerlix off the right lower extremity, as WOCN FF opened another package of "Silicone Safetac" (brand of wound care product) with the third pair of gloves. WOCN FF discarded the gloves, and sanitized her hands.

-WOCN FF then donned three new pairs of gloves and assisted RN P to remove the remainder of the Kerlix dressing off Patient #1's right lower extremity by spraying normal saline onto the silicone. WOCN FF identified the Kerlix sticks sometimes because of the drainage. Patient #1 was observed to quietly cry and occasionally moan during the dressing change.

-WOCN FF directed RN P hold Patient #1's right foot up and Patient #1 cried out. WOCN FF questioned Patient #1 about where it hurt and received a response it all hurt.

-WOCN FF continued to pull the previous silicone cover off the open, red area. The silicone cover was particularly sticky on the posterior right ankle/lower extremity. Patient #1 expressed pain during this process.

-WOCN FF discarded one layer of gloves and opened a package of Kerlix.

-WOCN FF poured Iodine onto sterile 4 x 4, then opened the Silicone cover package.

-WOCN FF wiped or dabbed the right lower extremity with normal saline and a 4 x 4 up and down, then side to side repeatedly on the right lower extremity. The observation revealed an open area on the posterior right lower extremity the approximate size of a quarter. WOCN FF reported she drained the blisters so they wouldn't pop.

-WOCN FF discarded the second layer of gloves, then applied a silicone cover to the posterior right lower extremity. Patient #1 exhibited pain and winced during this process.

-WOCN FF cut a piece of silicone covering with the same scissors used to remove the dressing and placed the silicone covering onto Patient #1's right lower ankle/leg.

-WOCN FF blotted the right lower extremity with the Iodine covered 4 x 4, as Patient #1 continued to cry. WOCN FF replied it probably all stings and hurts everywhere.

-WOCN FF wrapped the right lower extremity while the iodine was still damp. WOCN FF wrapped Kerlix toes up and over the wounds, then back down to the ankle, and secured with tape.

d. Following the dressing change, WOCN FF reported she failed to measure the ten areas and blisters because they are all over each leg.

According to WOCN FF the goal of wound care was to decrease risk of infection and attempt to dry up the blistered areas. Patient #1 has a history of lower extremity edema, that factors into the care.

Patient #1's family previously informed WOCN FF Patient #1 typically wears TED (support stockings) hose, for antiembolism (blood clot prevention) not for compression and edema. WOCN FF reported the use of TED hose ended years ago.

e. During an interview on 10/10/17 at 3:15 PM, the Director of Accreditation and Regulatory Services reported the acute care hospital lacked a policy related to double or triple gloving during a dressing change. She added that was not a hospital policy and the nursing standard does not direct that type of practice.

f. An interview on 10/4/17 at 12:49 PM, Physician XX, infection specialist and physician for the wound care center, identified there are other options to consider for dressing changes if they cause pain to a patient such as if the dressing is drying too much and the wounds are superficial, Silvadene (ointment) may be an option to consider if appropriate. Treatment for blisters are similar to that of a burn. Pain medication, or if needed staff may call the sedation team to complete the dressing change under sedation.

Physician XX was not familiar with the use of three pairs of gloves for dressing changes and never observed that practice before. From an infection prevention standpoint the expectation was the nurse removed the soiled gloves, sanitize hands, then replace gloves for the next part of the dressing change. Physician XX reported currently Patient #1's wounds don't appear infected, but certainly could happen because any time the skin is open, there is a risk for infection.

Physician XX relayed there are a number of different options available other than Iodine for patient comfort. That's unacceptable, and we need to reassess treatment options.

4. Review of Patient #2's medical record documented the following:
a. An admission date of 9/22/17 at 3:06 AM, revealed Patient #2 presented to the Emergency Department (ED) with a chief complaint of constant abdominal pain that began four hours prior. Patient #2 rated the pain at a 4 out of 10. Patient #2 reported pain medication prescribed for the 8/31/17 surgical procedure to remove uterine cancer was not effective.

b. Review of physician notes revealed the following:

1) A History and Physical (H&P) consultation note, dated 9/23/17, listed Patient #2's status was admitted for abdominal pain not relieved by current medications. Pain medication included Fentanyl PCA (Patient Controlled Analgesia), 50 micrograms (mcg)/1 milliliter (ml), in a 1500 mcg syringe/vial.

2) A H&P consultation note, dated 9/25/17 at 12:23 PM, identified Patient #2 as resting in bed and feels "ok." Patient #2 reported some abdominal pain around the incision and dressing. Patient #2 described the pain as continuous lower quadrant/mid abdominal pain. Pain medication included Fentanyl PCA, 50 mcg /1ml, in a 1500 mcg syringe/vial.

3) A H&P consultation note, dated 9/26/17 at 3:07 PM, revealed Patient #2 in bed, about to shower and is "doing well." The patient reported abdominal pain and is alert and oriented. Pain medication included Fentanyl PCA, 50 mcg/1ml, in a 1500 mcg syringe/vial.

4) A Progress Note, dated 9/30/17, revealed a surgical procedure performed for evacuation of a large intraperitoneal (abdominal) hematoma (blood clot) measuring 15 x 11 x 19 centimeters (cm). Physician orders directed to continue pain management after surgery. Current medications included pain medication, Fentanyl PCA, 50 mcg/1 ml, 1500 mcg.

c. Patient #2's interview on 10/3/17 at 9:35 AM, reported terrible pain on the left side after the second surgical procedure to remove the large blood clot. Patient #2's pain pump worked, however he/she was told that it could cause an overdose. Patient #2 revealed the PCA was not used from 9:30 AM until about 7:00 PM on 10/1/17 and experienced lots of pain. Patient #2 called their spouse crying because of the pain intensity.

According to Patient #2, RN Q put the PCA button above the IV pump (the pump used to deliver intravenous fluids at a specific rate.) RN Q replied to Patient #2 we don't want you to overdose, and you need to give the Tylenol time to work. Patient #2 responded if a person tells you that a medicine could hurt you, of course you aren't going to use it. Patient #2 identified experiencing a lot of pain that day.

When the night shift nurse (RN G) came in, Patient #2 reported pain and the nurse directed the patient to use the PCA button. Patient #2 was tearful and informed RN G the PCA button was located on the IV pump out of reach and no other nurse or staff saw the PCA button on the IV pump or offered it to the patient.

d. RN G's interview on 10/11/17 at 3:34 PM, revealed she entered Patient #2's room as the patient and PCT H ambulated from the bathroom. Patient #2 reported pain at a 10 out of 10. RN G asked Patient #2 why he/she did not use the PCA? Patient #2 responded because the doctor stopped it and RN Q directed the patient not to use the PCA because they started Tylenol and the doctor didn't want the patient to overdose.

RN G reported Patient #2 had increased pain, and showed the patient the physician's order to prove it was ok to use the PCA medication. Patient #2 cried and was upset because of suffering so much pain.

e. PCT H's interview on 10/11/17 at 4:36 PM, PCT H identified Patient #2 as a very pleasant patient. The patient does not use the call light a lot. The patient appeared to have increased pain when assisted to the bathroom. PCT H encouraged Patient #2 to push the PCA button, and could because it was green. The patient did not push the button and reported it didn't work anymore. PCT H informed RN G, and RN G changed the PCA medication vial for Patient #2.

f. During an interview on 10/16/17 at approximately 2:43 PM, PCT R identified she worked with RN I after Patient #2's surgical procedure and responded Patient #2 experienced a lot of pain and difficulty getting up at first. According to PCT R she reported the pain to RN I and she then increased the PCA and started Acetaminophen (Tylenol) every 2 hours for Patient #2.

g. RN I's interview on 10/18/17 at 1:30 PM, revealed the first night after surgery, Patient #2's pain was not under control. RN I received physician orders to increase the PCA and an order for intravenous Tylenol. RN I stated she provided nursing cares for Patient #2 the night after the 9/29/17 surgical procedure at 7:00 PM. RN I noticed the PCA button hanging on the IV pump when she cleared the PCA and noticed the patient did not use the PCA at all. Patient #2 confirmed to RN I about not using the PCA. RN I thought the patient did not have pain not being aware of the lack of understanding for Patient #2 on the use of the PCA.

RN I recalled the first night the patient refused to dangle at the edge of the bed because of so much pain. She couldn't recall anything about the second night. According to RN I sometimes patients are afraid to ask for pain medication and did not think Patient #2 was in pain because of the intravenous Tylenol started earlier.

h. The interview on 10/17/17 at 9:24 AM with RN Q identified she did not tell Patient #2 not to use the PCA and did not say the patient would overdose. RN Q felt it was a misunderstanding. RN Q could not recall specific information regarding clearing the PCA pump. She did recall the patient received IV Tylenol. RN Q hung the bag of Tylenol and provided patient education regarding the medication.

i. Review of Patient #2's clinical record with the Associate Chief of Nurses revealed:

1) On 9/30/17 at 1:42 PM, RN Q cleared the PCA pump. Documentation revealed on 9/29/17 at 4:30 AM through 9/30/17 at 1:42 PM, Patient #2 attempted to use the PCA 14 times, and received pain medication 10 times. Patient #2 received a total of 160 mcg of Fentanyl over approximately 9 hours.

2) On 9/30/17 at 8:47 PM RN I cleared the PCA pump and documented there were no attempts to use the PCA pump, and no PCA pain medication administered.

3) Review of the pharmacy narcotic administration record revealed RN I signed and dispensed Fentanyl 50 mcg PCA on 9/29/17 at 8:01 PM. The pharmacy narcotic administration record failed to indicate RN I removed Fentanyl on 9/30/17.

4) Review of the pharmacy narcotic administration record revealed on 10/1/17 at 4:11 AM, RN G signed and dispensed Fentanyl 50 mcg PCA.

5) Review of the acute care hospital Medication Incident log revealed on 10/1/17 at 11:45 PM, Patient #2 reported pain at 10 out of 10. Patient #2 reported the day RN discontinued the PCA and changed to intravenous Tylenol. Patient #2 reported to have excruciating pain and suffered all day.