HospitalInspections.org

Based on observation, interview, and record review, the facility failed to ensure nursing staff supervised and evaluated the care for :

a. one (1) of 4 current patients with a medication allergy who was not provided a red allergy band upon admission per facility policy [ Patient ID # 6] ;

b. two (2) of 2 discharged patients medicated for pain were not reassessed per facility policy after administration of pain medication [Patient ID # 1, 3].

These deficient practices could contribute to medication errors and ineffective pain management for patients.

Findings included:

TX00411682

a. Medication Allergy:

Record review of facility policy titled:"Hospital Color-Coded Alert Wristbands,"dated 06/25/2021, showed:

-Purpose: to create a standardized process that identifies and communicates patient-specific risk factors or special needs.
-Allergy: every patient should receive a red arm band at the time of initial assessment including those patients with No Known Drug Allergies(NKA).
-The white surface on band is for noting NKA or allergies when allergies are documented in the medical record.

Record review on 3/14/2022 of the J7MA Oncology floor 'Patient List' showed a current census of 31 patients.

During an interview on 03/14/2022 at 1:30 PM with Staff D, charge nurse, he reviewed the current shift report information and identified several patients with documented medication allergies. He stated all patients with medication allergies were required to have these allergies noted on a red arm band placed at admission.

Observation on 3/14/2022 between 1:30 and 1:50 PM- the charge nurse and surveyor entered the rooms of of four (4) randomly selected patients with documented medication allergies.

Room 27:

Patient ID # 6 was asked if she had medication allergies. She said "yes, I am allergic to sulfa drugs." Patient ID# 6 was not wearing a red allergy band; she confirmed she was not given one. This observation was verified by Staff D, charge nurse. He stated Patient ID # 6 should have been provided the red allergy band on admission.

This allergy to sulfa drugs was noted in Patient ID # 6's medical record.

b. Pain management :

Record review of facility policy titled: "Pain Assessment and Management," dated 06/19/2019, showed:

-Purpose statement : to outline a process to provide optimal patient comfort.

- Procedure statement: patients have the right to have their pain assessed and appropriately managed...effective pain management is an important indicator of quality of care.

Section H- Interventions:...4. Monitor, reassess, and document effectiveness of pharmacologic interventions at the following intervals:...b. IV medications : adults : 30-60 minutes ( 0.5- 1.5 hours) after administration.

Patient ID # 1:

Review of Patient ID #1's medical record showed she was a 57- year-old female patient admitted to ER on 1/15/2022 with complaints of trouble breathing and left knee pain and increased swelling. She had a history of hypertension, diabetes, implantable defibrillator, and heart failure.

-1/15/2022 : pain was assessed at 9/10: MS 4 mg. IV given at 1833 ; no reassessment of pain.

-1/16/2022: pain was assessed at 10/10 : MS 4 mg. IV given at 0103 ; no reassessment of pain until 0416, over 3 hours later.

Patient ID # 3:

Review of Patient ID #3's medical record showed she was a 48- year- old female patient admitted on 1/25/2022 with diagnosis of left side abdominal pain with nausea& vomiting and history of pancreatic pseudocyst, pancreatitis, and acute COVID-19.

-1/25/2022 : pain was documented at level 8/10- Four (4) milligrams (mg) Morphine sulfate (MS) administered IV on 1/25/2022 at 1047 AM.

-Pain was not reassessed until 1/25/2022 at 1445, almost four hours later. On 1/25/2022 at 1445, it was documented "pain reduced."


The above findings related to pain reassessment for Patients ID # 1 and 3 were verified by Staff B, Director of Quality at the time of record review.