HospitalInspections.org

Based on policy and procedure review, medical record review and staff interview, the hospital's nursing staff failed to supervise and evaluate patient care by failing to assess and reassess patients receiving pain medication for 5 of 7 patients receiving pain medications.(#2, 3, 4, 11, and 14).

The findings include:

Review of the hospital's policy and procedure "Patient Controlled Analgesia (PCA): Alaris PCA Module - PCA and Epidural Use," revised/reviewed date of 08/2012 the "...clinical data procedure is: Upon patient arrival to the unit and after every program adjustment or setting change observe the patient's comfort level, level of consciousness, vital signs, and pulse oximeter: ... pain and sedation assessments every 1 hour times 2, every 2 hours times 22 hours for a total of 24 hrs, then every 4 hours for the duration of the PCA unless otherwise indicated. When a dose change occurs the patient will be reassessed every 30 minutes times two then return to current time schedule of every 2 hours or every 4 hours. ..."

1. Open medical record review of Patient #2 revealed a 77 year old female admitted on 11/26/2012 for abdominal pain and diverticulitis followed by surgery, open sigmoid colon resection with proctoscopy on 11/26/2012. Documentation on the MAR (medication administration record) revealed pain management post-operatively was Morphine (narcotic pain medication) delivered through a PCA device started on 11/26/2012 at 1659. Review of the pain assessment flow sheet revealed the pain assessment was documented on 11/26/2012 at 1940. The next pain assessment was documented on 11/27/2012 at 0750 (12 hours and 10 minutes after prior assessment).

An interview on 11/28/2012 at 0820 with RN #1 revealed "The pain assessment is documented on the pain assessment flow sheet on 11/26/12 at 1700 then not documented again until day shift on 11/27/2012. The pain assessment is not documented every 2 hours. For a PCA..... the patient's pain is monitored every 2 hours." The interview confirmed the nursing staff failed to assess/reassess a patient's pain every 1 hour times 2 then every 2 hours times 22 hours per the hospital's policy for Patient Controlled Analgesia.

2. Open medical record review of Patient #11 revealed a 31 year old female admitted with appendicitis on 11/27/2012 at 2220 and taken to surgery that same night at 2300. Post-operatively (after surgery) the patient was returned to the assigned room on the surgical unit Documentation on the MAR (medication administration record) revealed pain management post-operatively was Morphine (narcotic pain medication) delivered through a PCA device initiated on 11/28/2012 at 0243. The first documented pain assessment is on 11/28/2012 at 0400 (1 hour and 17 minutes past the initiation of the PCA infusion). The next documented pain assessment is on 11/28/2012 at 0654 (2 hours and 54 minutes past the prior documentation).

An interview on 11/28/2012 at 1040 with RN #3 revealed "the pain assessment was documented twice by the 11pm - 7am shift on 11/28/2012 and it should have been documented every 2 hours with a PCA. The policy says the pain assessment for patients with a PCA are to be done every 1 hour times 2 then every 2 hours and that is not documented in the chart". The interview confirmed the nursing staff failed to assess/reassess the patient's pain every 1 hour times 2 hours then every 2 hours time 22 hours for a total of 24 hours per the hospital's policy for Patient Controlled Analgesia.

3. Open medical record review of Patient #14 revealed a 68 year old male admitted 11/27/2012 with diagnosis of left kidney mass with scheduled surgery on 11/27/2012. Review of the MAR reveals a PCA Epidural infusion with fentanyl-bupivacaine (pain medication) was initiated on 11/27/2012 at 1440 in the Post Anesthesia Care Unit (PACU) for postoperative pain management. The patient then returned to their assigned room on the surgical unit. Review of the pain assessment flow sheet reveals a pain assessment is documented on 11/27/2012 at 1559 (1 hour and 19 minutes past initiation of the PCA). The next documented pain assessment is on 11/27/2012 at 2000 (3 hours and 59 minutes after the prior assessment). Review of the pain assessment flow sheet reveals a pain assessment documented on 11/28/2012 at 2400 (4 hours after the prior assessment). The next documented pain assessment is on 11/28/2012 at 0800 (8 hours past the prior assessment).

An interview on 11/28/2012 at 1040 with RN#3 revealed "the pain assessment has been documented every 4 hours. The policy for pain assessment of patients who have a PCA or an epidural PCA is every 2 hours....on this chart the .... the pain (assessment) was documented only twice by the 7pm - 7am shift and it should have been documented every 2 hours". The interview confirmed the nursing staff failed to assess/reassess a patient's pain per the hospital's policy of every 1 hour times 2 after initiation of the PCA then every 2 hours times 22 hours for Patient Controlled Analgesia.

4. Closed medical record review of Patient #3 revealed a 43 year old female admitted on 10/06/2011 through the Emergency Room (ER) with diagnosis of acute appendicitis with surgery, a laparoscopic appendectomy, performed that same day. Documentation in the Nurses Notes revealed the patient returned from the PACU (post anesthesia care unit) on 10/06/2011 at 1810. Review of the Nursing Assessment Forms and the MAR revealed documentation that the Morphine (pain medication) PCA was initiated on 10/06/2011 at 1316 with a loading dose of 6 milligrams. There is no documented reassessment of the patient's pain at the required time of 1416. Continued review of the Assessment Forms revealed the Morphine PCA was reinitiated postoperatively on 10/06/2011 at 1819 after the patient returned to the assigned room on the surgical unit. Further review of the pain assessment flow sheet reveals there is no reassessment of the patient's pain one hour after the reinitiation of the PCA infusion. Further review of the pain assessment flow sheet revealed the first documented post operative pain assessment is on 10/06/2011 at 2000 (1 hour and 41 minutes past the initiation of the PCA). The next documented pain assessment is on 10/06/2011at 2048. Further review revealed the next documented pain assessment is on 10/07/2011 at 0800 (12 hours and 48 minutes past the prior assessment).

An interview on 11/27/2012 at 1415 with RN #2 revealed "the pain assessment documented on the pain assessment flow sheet was documented only once postoperatively. The documentation (pain assessment) is just not there". The interview confirmed the nursing staff failed to assess/reassess a patient's pain per the hospital's policy of every 1 hour times 2 after initiation of the PCA then every 2 hours times 22 hours for Patient Controlled Analgesia

5. Closed medical record review of Patient #4 revealed a 53 year old female admitted on 10/06/2011 with diagnosis of abdominal pain and diverticulitis who was subsequently taken to surgery on 10/12/2011. Post operatively (after surgery) the patient was returned to the assigned room on the surgical unit. Review of the nursing assessment form revealed documentation of a Morphine (narcotic pain medication) PCA on 10/12/2011 at 1600. Review of the pain assessment flow sheet revealed the pain assessment was documented on 10/12/2011 at 1600. The next documented pain assessment is on 10/12/2011 at 1800 (2 hrs after the prior assessment). The pain assessment flow sheet revealed a pain assessment documented on 10/13/2011 at 0845 (14 hours and 45 minutes after the prior assessment). The next documented pain assessment is on 10/13/2011 at 1200 (4 hours and 45 minutes after the prior assessment). The next documented pain assessment is on 10/13/2011 at 2000 (8 hours after the prior documentation).

Interview with RN #2 on 11/27/2012 revealed "the pain assessment is not documented every 1 hour times 2 then every 2 hours as it should be with the PCA". The interview confirmed the nursing staff failed to assess/reassess a patient's pain per the hospital's policy of every 1 hour times 2 after initiation of the PCA then every 2 hours times 22 hours for Patient Controlled Analgesia.

NC00077692
NC00081136

Based on policy and procedure review, medical record review and staff interview, the hospital's nursing staff failed to supervise and evaluate patient care by failing to assess and reassess patients receiving pain medication for 5 of 7 patients receiving pain medications.(#2, 3, 4, 11, and 14).

The findings include:

Review of the hospital's policy and procedure "Patient Controlled Analgesia (PCA): Alaris PCA Module - PCA and Epidural Use," revised/reviewed date of 08/2012 the "...clinical data procedure is: Upon patient arrival to the unit and after every program adjustment or setting change observe the patient's comfort level, level of consciousness, vital signs, and pulse oximeter: ... pain and sedation assessments every 1 hour times 2, every 2 hours times 22 hours for a total of 24 hrs, then every 4 hours for the duration of the PCA unless otherwise indicated. When a dose change occurs the patient will be reassessed every 30 minutes times two then return to current time schedule of every 2 hours or every 4 hours. ..."

1. Open medical record review of Patient #2 revealed a 77 year old female admitted on 11/26/2012 for abdominal pain and diverticulitis followed by surgery, open sigmoid colon resection with proctoscopy on 11/26/2012. Documentation on the MAR (medication administration record) revealed pain management post-operatively was Morphine (narcotic pain medication) delivered through a PCA device started on 11/26/2012 at 1659. Review of the pain assessment flow sheet revealed the pain assessment was documented on 11/26/2012 at 1940. The next pain assessment was documented on 11/27/2012 at 0750 (12 hours and 10 minutes after prior assessment).

An interview on 11/28/2012 at 0820 with RN #1 revealed "The pain assessment is documented on the pain assessment flow sheet on 11/26/12 at 1700 then not documented again until day shift on 11/27/2012. The pain assessment is not documented every 2 hours. For a PCA..... the patient's pain is monitored every 2 hours." The interview confirmed the nursing staff failed to assess/reassess a patient's pain every 1 hour times 2 then every 2 hours times 22 hours per the hospital's policy for Patient Controlled Analgesia.

2. Open medical record review of Patient #11 revealed a 31 year old female admitted with appendicitis on 11/27/2012 at 2220 and taken to surgery that same night at 2300. Post-operatively (after surgery) the patient was returned to the assigned room on the surgical unit Documentation on the MAR (medication administration record) revealed pain management post-operatively was Morphine (narcotic pain medication) delivered through a PCA device initiated on 11/28/2012 at 0243. The first documented pain assessment is on 11/28/2012 at 0400 (1 hour and 17 minutes past the initiation of the PCA infusion). The next documented pain assessment is on 11/28/2012 at 0654 (2 hours and 54 minutes past the prior documentation).

An interview on 11/28/2012 at 1040 with RN #3 revealed "the pain assessment was documented twice by the 11pm - 7am shift on 11/28/2012 and it should have been documented every 2 hours with a PCA. The policy says the pain assessment for patients with a PCA are to be done every 1 hour times 2 then every 2 hours and that is not documented in the chart". The interview confirmed the nursing staff failed to assess/reassess the patient's pain every 1 hour times 2 hours then every 2 hours time 22 hours for a total of 24 hours per the hospital's policy for Patient Controlled Analgesia.

3. Open medical record review of Patient #14 revealed a 68 year old male admitted 11/27/2012 with diagnosis of left kidney mass with scheduled surgery on 11/27/2012. Review of the MAR reveals a PCA Epidural infusion with fentanyl-bupivacaine (pain medication) was initiated on 11/27/2012 at 1440 in the Post Anesthesia Care Unit (PACU) for postoperative pain management. The patient then returned to their assigned room on the surgical unit. Review of the pain assessment flow sheet reveals a pain assessment is documented on 11/27/2012 at 1559 (1 hour and 19 minutes past initiation of the PCA). The next documented pain assessment is on 11/27/2012 at 2000 (3 hours and 59 minutes after the prior assessment). Review of the pain assessment flow sheet reveals a pain assessment documented on 11/28/2012 at 2400 (4 hours after the prior assessment). The next documented pain assessment is on 11/28/2012 at 0800 (8 hours past the prior assessment).

An interview on 11/28/2012 at 1040 with RN#3 revealed "the pain assessment has been documented every 4 hours. The policy for pain assessment of patients who have a PCA or an epidural PCA is every 2 hours....on this chart the .... the pain (assessment) was documented only twice by the 7pm - 7am shift and it should have been documented every 2 hours". The interview confirmed the nursing staff failed to assess/reassess a patient's pain per the hospital's policy of every 1 hour times 2 after initiation of the PCA then every 2 hours times 22 hours for Patient Controlled Analgesia.

4. Closed medical record review of Patient #3 revealed a 43 year old female admitted on 10/06/2011 through the Emergency Room (ER) with diagnosis of acute appendicitis with surgery, a laparoscopic appendectomy, performed that same day. Documentation in the Nurses Notes revealed the patient returned from the PACU (post anesthesia care unit) on 10/06/2011 at 1810. Review of the Nursing Assessment Forms and the MAR revealed documentation that the Morphine (pain medication) PCA was initiated on 10/06/2011 at 1316 with a loading dose of 6 milligrams. There is no documented reassessment of the patient's pain at the required time of 1416. Continued review of the Assessment Forms revealed the Morphine PCA was reinitiated postoperatively on 10/06/2011 at 1819 after the patient returned to the assigned room on the surgical unit. Further review of the pain assessment flow sheet reveals there is no reassessment of the patient's pain one hour after the reinitiation of the PCA infusion. Further review of the pain assessment flow sheet revealed the first documented post operative pain assessment is on 10/06/2011 at 2000 (1 hour and 41 minutes past the initiation of the PCA). The next documented pain assessment is on 10/06/2011at 2048. Further review revealed the next documented pain assessment is on 10/07/2011 at 0800 (12 hours and 48 minutes past the prior assessment).

An interview on 11/27/2012 at 1415 with RN #2 revealed "the pain assessment documented on the pain assessment flow sheet was documented only once postoperatively. The documentation (pain assessment) is just not there". The interview confirmed the nursing staff failed to assess/reassess a patient's pain per the hospital's policy of every 1 hour times 2 after initiation of the PCA then every 2 hours times 22 hours for Patient Controlled Analgesia

5. Closed medical record review of Patient #4 revealed a 53 year old female admitted on 10/06/2011 with diagnosis of abdominal pain and diverticulitis who was subsequently taken to surgery on 10/12/2011. Post operatively (after surgery) the patient was returned to the assigned room on the surgical unit. Review of the nursing assessment form revealed documentation of a Morphine (narcotic pain medication) PCA on 10/12/2011 at 1600. Review of the pain assessment flow sheet revealed the pain assessment was documented on 10/12/2011 at 1600. The next documented pain assessment is on 10/12/2011 at 1800 (2 hrs after the prior assessment). The pain assessment flow sheet revealed a pain assessment documented on 10/13/2011 at 0845 (14 hours and 45 minutes after the prior assessment). The next documented pain assessment is on 10/13/2011 at 1200 (4 hours and 45 minutes after the prior assessment). The next documented pain assessment is on 10/13/2011 at 2000 (8 hours after the prior documentation).

Interview with RN #2 on 11/27/2012 revealed "the pain assessment is not documented every 1 hour times 2 then every 2 hours as it should be with the PCA". The interview confirmed the nursing staff failed to assess/reassess a patient's pain per the hospital's poli