HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 7 (Pt. #1) records reviewed for pain management, the Hospital failed to ensure that the registered nurse supervised and evaluated the nursing care provided for pain management.

Findings include:

1. The Hospital's policy titled, "Pain Management" (revised 7/18/2018), was reviewed on 11/10/2020 and required, "...Evaluation and documentation of response to intervention is required and should include progress toward pain management goals... Documentation of... interventions for pain... are completed in the EMR [electronic medical record] by the individual with the appropriate level of training and licensure..."

2. The clinical record of Pt. #1 was reviewed on 11/10/2020. Pt. #1 was admitted on 1/8/2020, with a diagnosis of exacerbation of heart failure. Pain assessments from 1/8/2020-1/20/2020 were reviewed and the record lacked documentation of pain interventions for the following pain assessments:
- 1/14/2020 at 8:00 AM: Pain 10/10; Dissatisfied; Location: Chest/Back
- 1/16/2020 at 8:41 AM: Pain 10/10; Dissatisfied; Location: Chest

3. An interview was conducted with a Registered Nurse (E#7) on 11/10/2020 at 2:27 PM. E#7 stated that if pain is not at an acceptable level, interventions for pain management should be documented in the record to show that pain was addressed, including both pharmacological and non-pharmacological interventions.

Based on observation, document review and interview, it was determined that for one (Pt. #7) of 6 patients observed for lunch tray safety handling, the Hospital failed to manage dietary services by not ensuring the bowl with cut fruits in the lunch tray was covered.

Findings include:

1. On 11/10/2020 between 11:30 AM - 12:45 PM, an observational tour of the 15 West - Medical Unit/Covid Unit was conducted. During the tour the following was observed:

- At approximately 12:15 PM, a lunch tray for Pt. #7 was placed outside of Pt.#7's room, by the door near the isolation cabinet and was left unattended. The food tray had fresh fruit bowl with pineapple slices, apple slices and grapes left open with no lid.

2. On 11/10/2020 at approximately 2:30 PM, the Hospital's policy titled, "Isolation Food Service - Policy #C010" dated 01/18 was reviewed and included, " ...disposable dishes, trays and eating utensils are used ...all food items on the tray are covered ..."

3. On 11/12/2020 at approximately 8:45 AM, the Job Description of the Director of Food and Nutritional Services dated 03/2006 was reviewed and included, "....evaluates the production safe handling and quality of all food prepared and distributed to ensure that it is consistent ...for quality food service..."

4. On 11/10/2020 at approximately 12:18 PM, the Nurse Manager (E #4) was interviewed. E #4 stated that, it's unacceptable, the fruit bowl should have been covered.

5. On 11/12/2020 at approximately 9:00 AM, the Director of Food and Nutritional Services (E #6) was interviewed. E #6 stated that, the expectation is the food tray should have been left in the food cart and nurse gives it directly to the isolation patient, while the food tray was left outside it should not have been left uncovered.