HospitalInspections.org

Based on medical record review, facility policies and procedures, and staff interviews, it was determined that the facility failed to provide evaluation on an on-going basis as it relates to nursing care and pain management when two patients (P) (P#1 and P#2) of five (P#1, P#2, P#3, P#4, P#5) patients reported severe pain scores and no pain score reassessment was documented.


Findings included:


A review the facility's policy titled "Assessment of Patients," last effective date 10/2023, revealed that the purpose was to define the activities of each discipline that comprises the patient assessment function. Qualified individuals assess each patient's need for care or treatment. These assessments include the patient's physical, psychological, and social status and continue throughout the patient's contact with the organization.
Continued review revealed, Registered Nurse (RN) Assessments and Re-Assessments, an RN assesses the patient's need for nursing care in all settings in which nursing care is provided. Assessment of the patient's nursing care needs will include consideration of any information on biophysical, pain level, psychosocial, self-care, environmental, educational, and discharge planning and referral/community factors.


A review of the facility's policy titled "Rights and Responsibilities of Patients," effective 10/23, revealed that the purpose was to affirm and document the inherent and basic rights of all patients at the facility.
Pain Management: Patients have a right to appropriate assessment of pain. The patient's pain will be assessed and reassessed at appropriate intervals. The patient has the right to participate in decisions regarding the management of pain.


A review of the facility's policy titled "Pain Management," last effective 10/2023, revealed that the purpose of the policy was to detail that it is the policy of the facility to respect and support the patient's right to optimal pain management. Pain will be assessed in all patients. It is the responsibility of all clinical staff to assess all patients at admission about the presence of pain and periodically reassess the patient for patient and relief from pain.
Continued review revealed:
12. The patient will be reassessed within two hours after each pain control intervention according to the following:
" Progress toward pain management goals including functional ability.
13. Reassessment of pain after pharmacologic intervention will be documented in the patient record.
16. For patients in the Emergency Department, Pain assessments and reassessments are:
a. The patient shall undergo reassessment of paint within 60 minutes after every paint control mechanism employed by patient care providers.
b. Prior to discharge or transfer to the floor.


1. P#1's medical record revealed that on 6/3/24 at 10:56 a.m., P#1 had a pain score of 9 out of 10.


P#1's medical record revealed that P#1 was administered morphine (pain medication used to treat moderate to severe pain) on 6/3/24 at 1:11 p.m. P#1's medical record failed to reveal a pain level reassessment.


P#1's medical record revealed that on 6/3/24 at 3:17 p.m., hydrocortisone (steroid medication used to calm down body's immune response to reduce pain and swelling) rectal cream was ordered for twice daily. Continued review of P#1's medical record revealed that the medication was administered on 6/3/24 at 3:48 p.m. P#1's medical record failed to reveal a pain level reassessment.


P#1's medical record revealed that on 6/3/24 at 6:32 p.m., hydrocodone-acetaminophen (Norco) (medication used for management of pain) was ordered as a one-time dose. Continued review of P#1's medical record revealed that the medication was administered on 6/3/24 at 8:07 p.m. P#1 reported a pain score of 10 out of 10. Continued review of P#1's medical record failed to reveal a pain level reassessment.


2. A review of P#2's medical record revealed that on 10/2/24 at 10:54 p.m. P#2 reported a pain score of 10 out of 10. Continued review failed to reveal a post-intervention pain score was documented two hours afterwards.


P#2's medical record revealed that on 10/3/24 at 8:14 p.m., P#2 reported a pain score of 10 out of 10. Continued review failed to reveal a post-intervention pain score was documented two hours afterwards.


P#2's medical record revealed that on 10/4/24 at 3:10 a.m., P#2 reported a pain score of nine out of 10. Continued review failed to reveal a post-intervention pain score was documented two hours afterwards.


P#2's medical record revealed that on 10/4/24 at 9:35 a.m., P#2 reported a pain score of eight out of 10. Continued review failed to reveal a post-intervention pain score was documented two hours afterwards.


P#2's medical record revealed that on 10/4/24 at 3:19 p.m., P#2 reported a pain score of 10 out of 10. Continued review failed to reveal a post-intervention pain score was documented two hours afterwards.


During an interview on 11/6/24 at 10:56 a.m. in the conference room, Wound Care Educator (WCE) CC said that when a Registered Nurse (RN) conducts a pain assessment, the RN should use the appropriate scale and method. WCE CC said that the appropriate pain medication should be administered that matches the patient's stated pain level. WCE CC said that a reassessment of pain should be conducted and charted after medication administration to see if the patient requires additional pain relief. WCE CC said that there are some circumstances in which pain medication cannot be administered such as if the patient's blood pressure is low or if it will cause damage to the patient.


During an interview on 11/6/24 at 2:04 p.m. in the conference room, Nurse Manager (NM) DD said that when staff are to obtain a pain score on a patient upon admission and twice a shift. NM DD said that if the patient requests pain medication, the nurse should use the appropriate pain scale and retrieve the pain medication that is ordered for that patient's pain level. NM DD said that if there is no pain medication that is appropriate and ordered, then the nurse should contact the provider for pain medication. NM DD said that after pain medication is administered, the nurse should conduct a pain reassessment within two hours.


During a telephone interview on 11/6/24 at 2:40 p.m., Registered Nurse (RN) BB said that after pain medication is administered, a pain re-assessment should be done and documented in the patient's medical record.

Based on medical record review, facility policies and procedures, and staff interviews, it was determined that the facility failed to ensure that the medical records included sufficient documentation of patients leaving against medical advice when one patient (P) (P#1) of five (P#1, P#2, P#3, P#4, P#5) patients left the facility against medical advice (AMA) and the medical record did not include an AMA form notating that the risks and benefits were discussed or a progress note from a physician indicating the condition and disposition of the patient.


Findings included:


A review of the facility's policy titled "HIPAA - Providing Notice of Privacy Practices to Patients/Obtaining Patient Acknowledgement," last effective 10/2019, revealed that the purpose of the policy was to detail that the facility will provide or make available to each patient a Notice or Privacy Practices with the intent to explain to the patient how the facility will use and disclose protected health information (PHI), explain the patient's rights with respect to their PHI, and to explain the facility's legal duties with respect to the patient's PHI.

Continued review revealed the following:

Patient Acknowledgement, the facility is required to make a "good faith effort" to obtain written acknowledgement. If the facility is unable to obtain such an acknowledgement, it must document its good daith efforts to obtain it and the reason that those efforts were unsuccessful.

B, Inpatient Care, a good faith effort to obtain acknowledgement. The patient should be presented with the admission registration package, which should be placed in the patient's medical record.

E, Failure to Obtain Acknowledgement, if the patient refuses or otherwise fails to sign the acknowledgement, the staff member should write the reason for failing to obtain the written acknowledgement from the patient int eh space provided on the summary and acknowledgement form.


A review of the facility's policy titled, "Discharge Summary," last effective 09/2023, revealed that the purpose of the policy was to help ensure successful continuity and transition of patient care by effectively communicating information in the medical record pertinent to the care, treatment, and services provided during the hospitalization of the patient and the plan for post discharge care and follow up.
Continued review revealed, C, admissions 24 hours or less, inpatient, outpatient in a bed, or observation status, the final progress note may be substituted for the discharge summary provided the note contains the following, if applicable:

" Reason for hospitalization
" Procedure performed
" Care, treatment, and services provided
" Patient condition and disposition at discharge
" Information/education provided to patient and family
" Provisions for follow up care


A review of a "Nursing Note" dated 6/3/24 at 7:30 p.m., by Registered Nurse (RN) BB revealed that P#1 reported waiting for more than three hours for pain medicine and requested to be transferred. RN BB informed P#1 that the day shift RN had to get medication order placed and pain medication was now available. As RN BB retrieved pain medication for P#1, P#1 proceeded to yell and curse at staff in the hallway. RN BB contacted the on-call hospitalist and the Public Safety Officer (PSO) while Wound Care Educator (WCE) CC escorted P#1 back to his room. RN BB administered pain medication to P#1. RN BB instructed the PSO to remain outside as to not upset P#1. P#1 threatened to punch RN BB. RN BB informed the hospitalist of patient wishes, notified the Charge Nurse (CN). RN BB was informed by the hospitalist that he would be up there to speak with P#1.


Continued review of P#1's medical record revealed that P#1's disposition was set to left against medical advice (AMA) on 6/3/24 at 9:27 p.m.


During an interview on 11/6/24 at 1:30 p.m. in the conference room, Chief Medical Officer (CMO) FF said that he has been an emergency department (ED) physician since 2001 and the interim CMO for about four months. CMO FF said that in general when a patient requests to leave against medical advice (AMA), the nurse should notify the physician and then the physician should eventually have a discussion with the patient to discuss the risks and benefits. CMO FF said that the patient has a form they are to sign but sometimes the patient does not always sign it. CMO FF said that if patients do not sign the form or walk out prior to the physician seeing them, then the provider should document this in a note in the patient's chart. CMO FF said that it is his expectation that providers document that a patient left AMA from the facility in either a note or form.


During an interview on 11/6/24 at 1:45 p.m. in the conference room, Medical Doctor (EE) said that he has specialized in internal medicine and employed with the facility since 2021. MD EE said that he does not recall P#1.
MD EE said that in the event a patient wanted to leave against medical advice (AMA), the nurse is supposed to notify the provider and then the provider should go and discuss the risks of leaving with the patient. MD EE said that sometimes a provider cannot always make to the patient fast enough, especially if they are alerted while they are performing an invasive procedure such as a central line placement, but they should see the patient afterwards. MD AA said that the patient should sign an AMA form, but if the patient refuses to do this, then the provider should document that in the chart. MD EE said that his practice is to always leave a note in the patient's chart as a progress note if the patient left AMA, whether or not the patient signed the AMA form.


During an interview on 11/6/24 at 2:04 p.m. in the conference room, Nurse Manager (NM) DD said that when a patient is requesting to leave against medical advice (AMA), the nurse should attempt to de-escalate the situation, learn why the patient is requesting to leave, inform the physician, and then inform the patient that the physician is aware and coming to speak with the patient. NM DD said that once the physician speaks with the patient, staff should get the patient to sign an AMA form and then an incident report, RL-6, should be filed. NM DD said that the nurse should also document that the patient left the facility AMA as a nursing note in the patient's medical record. NM DD said that if the patient refused to sign the AMA form, then the RN should document this in the patient's medical record as well. NM DD said that it would be odd and not within policy or procedure if there was not either a nursing note or AMA form on file.


During a telephone interview on 11/6/24 at 2:40 p.m., Registered Nurse (RN) BB recalled that P#1 later told RN BB that he was going to contact another hospital and requested RN BB call the physician on-call to talk to P#1. RN BB recalled that she contacted MD GG, who told RN BB that after he finished up his current task, he would come up to see P#1. RN BB recalled that MD GG spoke with P#1 and then came by the nurses' station to spoke with RN BB. RN BB recalled that MD GG said that if P#1 was able to get an approval for a transfer then MD GG would sign it or if not and P#1 wanted to leave the facility then P#1 would be free to go as he discussed the risks with P#1 already. RN BB recalled that P#1 returned to his room, then later left the facility.
RN BB said that she has had some patients get very upset before in the past and threatened to leave AMA, but most did not after staff were able to provide quick resolution to their problems. RN BB said that she is aware of the AMA form and sometimes patients sign it, and sometimes they do not. RN BB said that she was not sure if staff had to still sign the AMA form if the patient did not sign it. RN BB recalled that her CN told her to document the entire event in P#1's medical record and RN BB did this as the incident with P#1 was very different.