HospitalInspections.org

Based on a review of clinical records, facility documentation and an interview with staff, the facility failed to ensure that staff followed an approved policy and procedure.

Findings were:

A review of the clinical record for patient #1 revealed that the patient was medicated with Morphine 6 mg intravenously at 12:30 pm along with Valium 5 mg orally at 12:35 pm for pain. The clinical record revealed no reassessment of the patient's pain level following this treatment.

In a subsequent interview with staff #1, he was asked to examine the medical record of Mr. Chaix and verify whether or not he was able to find documentation of pain reassessment following the 6 mg of morphine administered intravenously to Mr. Chaix on 1-19-14. He examined the record and concurred that no reassessment had been documented.

Facility policy and procedure titled Managing Pain in Adults (excluding Perinatal) stated, in part,
? Purpose - To provide guidelines for the optimal management of pain in adults who are not in the perinatal setting.
? Policy - It is the policy of the Seton Family of Hospitals to support the patient's right to optimal pain management while respecting the ethnic and cultural diversity of our patient population and their informed choices.
? Steps - 2. Reassess pain levels to ascertain efficacy and safety after administering a sedating pain medication.
a) The timing of this evaluation should be based upon the individual characteristics of the medication used and the clinical condition of the patient.
b) At a minimum reassess:
? At least every four hours or
? Every two hours during the first 24 hours post-operatively or
? More frequently if necessary
? Within 15 minutes of an IV dose
? Within 30 minutes of IM dose
? Within 1 hour of PO dose or
? As specified via a specific order
c) Reassessment documentation may include pain score, acceptable pain level, location, sedation scale score and respiratory rate.

The above was confirmed in an interview with the Quality Coordinator, the Director of Risk/Accreditation and the Director of Clinical Quality on the afternoon of 4-7-14 in the facility conference room.