HospitalInspections.org

Based on review of professional literature, policy and procedure review, record review, and staff interview, the Hospital failed to assess and document the effectiveness of medications given to patients on an as needed (PRN) basis for 5 of 20 active adult inpatient (Patients #1, #2, #3, #4, and #5) records reviewed. Failure to evaluate the patients' responses to PRN medications limited the nursing staff's ability to assess whether the medication achieved the desired effect or if the patients experienced any side effects or adverse reactions from the medication.

Findings include:

Berman and Snyder, "Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice," 9th ed., Pearson Education, Inc., New Jersey, 2012, page 862-870, states, ". . . Process of Administering Medications: When administering any drug . . . the nurse must do the following: . . . 6. Evaluate the client's response to the drug. . . . In all nursing activities, nurses need to be aware of the medications that a client is taking and record their effectiveness as assessed by the client and the nurse on the client's chart. . . . Skill 35-1 Administering Oral Medications: . . . Evaluation: Return to the client when the medication is expected to take effect (usually 30 minutes) to evaluate the effects of the medication on the client. Observe for desired effect . . ."

Review of the Hospital's policy regarding "Pain Management" occurred on 08/03/16. The policy, dated 06/06/16, stated: ". . . PURPOSE: 1. To establish a standard of care for pain assessment, management and patient comfort. 2. To provide guidelines for care of patients who report or exhibit signs or symptoms of pain. . . . POLICY: . . . 3. Pain is reassessed after any intervention to alleviate pain. . . . Documentation Hospital Nursing Units: 1. All interventions (non-pharmacological and pharmacological) used to alleviate pain are documented. 2. Documentation includes: a. Assessment score b. Intervention c. Reassessment score . . ."

Review of the Hospital's policy titled "Medication Administration" occurred on 08/03/16. This policy, reviewed/revised November 2015, stated, ". . . 10. Patients are reassessed for effectiveness of P.R.N. medications."

- Review of Patient #3's active medical record occurred on August 02-03, 2016 and identified the Hospital admitted the patient on 07/22/16 with diagnoses of schizoaffective disorder and chemical dependency. The record indicated the physician ordered PRN medications for both mild and moderate pain. These medications included:
* Tylenol 650 milligrams (mg) by mouth every six hours PRN for mild pain
* Tylenol 300 mg with codeine 30 mg (Tylenol #3) by mouth every six hours PRN for moderate pain

Patient #3's medication administration record (MAR) showed nursing staff administered the Tylenol 650 mg nine times between 07/24/16 through 08/01/16 and failed to reassess and/or document the patient's response to the medication in a timely manner on six of those occasions. On three of those six occasions no reassessment of the pain occurred prior to administering the next PRN dose. On three of those six occasions the reassessment of the pain occurred between four and eight hours later.

Patient #3's MAR showed nursing staff administered the Tylenol #3 also nine times between 07/24/16 through 08/01/16 and failed to reassess and/or document the patient's response to the medication in a timely manner on six of those occasions. On three of those six occasions no reassessment of the pain occurred prior to administering the next PRN dose. On three of those six occasions the reassessment of the pain occurred between two and seven hours later.

- Review of Patient #4's active medical record occurred on August 02-03, 2016 and identified the Hospital admitted the patient on 07/29/16 with diagnoses of suicidal ideation and major depression. The record indicated an order for Tylenol 650 milligrams by mouth every six hours PRN for mild pain.

Patient #4's MAR showed nursing staff administered the Tylenol on 07/30/16 at 5:43 p.m. for a headache and failed to reassess and/or document the patient's response to the medication until three hours later.

During interview on 08/02/16 at 9:25 a.m. a supervisory nurse (#5) stated she would expect nurses to reassess the patient's pain within one hour after administering these medications by mouth.



22495


- Review of Patient #5's active medical record occurred on August 02-03, 2016 and identified the Hospital admitted the patient on 07/31/16 with diagnoses of pre-eclampsia. The record showed the physician ordered prn oxycodone 10/325 mg every four hours for pain.

Patient #5's MAR showed nursing staff administered oxycodone three times on 08/01/16 and one time on 08/02/16 and failed to reassess the patient's response to the medication after administration.

During an interview on 08/02/16 at 3:40 p.m., the nurse manager (#15) stated she would expect nurses to reassess the patient's pain and document the assessment on the MAR.


32641


- Review of Patient #1's active medical record occurred on August 02-03, 2016 and identified the Hospital admitted the patient on 07/28/16 with diagnoses of abdominal pain, nausea, and status post mastectomy. The record indicated the physician ordered prn Ativan 0.5 mg every eight hours for anxiety.

Patient #1's MAR showed nursing staff administered the Ativan three times between 07/29/16 through 08/02/16 without completing and/or documenting an assessment before administration and reassessing and/or documenting the patient's response to the medication after administration.

- Review of Patient #2's active medical record occurred on August 02-03, 2016 and identified the Hospital admitted the patient on 07/26/16 with a diagnosis of a right colectomy [bowel resection]. The record indicated the physician ordered prn Tylenol 650 mg every six hours for mild pain and/or fever and Percocet 5-325 mg 1-2 tablets every six hours for moderate pain.

Patient #2's MAR showed nursing staff administered the Tylenol on 07/30/16 and the Percocet on 07/31/16 without reassessing and/or documenting the patient's response to either of the medications.

During an interview on the morning of 08/02/16, a supervisory nurse (#6) stated all prn medications should include a nursing assessment of the patient before administration and a reassessment within one hour after administration.