HospitalInspections.org

Based on interview and record review, the hospital failed to ensure the nursing services were provided for two of two sampled patients (Patients 1 and 2) as evidenced by:

1. The nursing staff did not ensure the pain management for Patients 1 and 2 as per the hospital's P&P.

2. The nursing staff did not irrigate the NG tube at least one per shift on 9/1 and 9/3/24, during the night shifts as per the hospital's P&P.

These failures created the increased risk of poor health outcomes to the patients receiving services in the hospital.

Findings:

1. Review of the hospital's P&P titled Pain Management dated 3/19/24, showed the general principles include the RN will assess the patient at the beginning of each shift and documenting the pain assessment. The RN is responsible for reassessing (post medication) the patient's pain after the medication is administered. Reassessment occurs between 30 to 60 minutes of administration: within 30 minutes for medications given IV route and 60 minutes for medications administered via oral or parenteral (SQ, IM) route. The RN notes the patient's reassessment number value (on a scale of 0 to 10 with 0 = no pain and 10 = most severe pain) and documents this in the Pain/Comfort/Sleep Flowsheet.

a. Review of Patient 1's closed medical record was initiated on 9/4/24 at 0815 hours. Patient 1's medical record showed the patient was admitted to the hospital on 8/8/24, and discharged on 8/26/24.

Review of the pain flowsheet showed on 8/15/24 at 1701 hours, showed Patient 1 had pain at the abdomen and the patient's pain level was 10 out of 10.

Review of the MAR showed Patient 1 was administered with hydromorphone (narcotic) 0.4 mg IV for pain level of 10 out of 10.

However, review of Patient 1's medical record failed to show documented evidenced of the pain level was reassessed 30 minutes after the pain medication was administered to the patient as per hospitals' P&P.

On 9/4/24 at 1043 hours, an interview and concurrent review of Patient 1's medical record was conducted with RN 1. RN 1 was asked if the pain assessment was completed. RN 1 stated the documentation was incomplete. RN 1 was further asked if they needed to reassess the pain level after the medication was given. RN 1 stated yes but it was not documented. RN 1 was further asked for the timeline of the reassessment after the medication was given. RN 1 stated half an hour after the intravenous pain medication was given. RN 1 was informed and acknowledged the findings.

On 9/4/24 at 1318 hours, the findings were shared with the Senior Principal Regulatory Compliance & Corporate Facilities, Chief Patient Safety Officer, Director of MS & Oncology, Manager of MS & Oncology, Patient Safety Lead RNs 1, 2 and 3. They reviewed the patient's medical record and hospital's P&P. They were informed the medical record was reviewed with the RN 1 and acknowledged the findings.


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b. On 9/4/24 at 1038 hours, review of Patient 2's medical record was conducted with Patient Safety Lead RN 1 and the Director of MS & Oncology. Patient 2's medical record showed the patient was admitted to the hospital on 8/25/24.

Review of Patient 2's History and Physical examination dated 8/25/24, showed the patient had a right pubic rami fracture (a break in one of the bones that make up the lower pelvis) after sustaining a fall.

Review of Patient 2's medical record did not show the RN had assessed Patient 2 for pain during the morning shift on 9/3/24.

In addition, review of Patient 2's medical record did not show the RN had reassessed the patient's pain after the patient reported a pain level of 8 out of 10 at the hip and was administered an IV pain medication on 9/4/24 at 0600 hours.

On 9/4/24 at 1122 hours, Patient Safety Lead RN 1 and the Director of MS and Oncology verified the above findings.

2. Review of the hospital's P&P titled Insertion, Irrigation and Removal of Nasogastric Tube dated 3/22/22, showed the NG tube will be checked for patency and irrigated at least once per shift and more often as per the nursing discretion.

On 9/4/24 at 1038 hours, review of Patient 2's medical record was conducted with Patient Safety Lead RN 1 and the Director of MS & Oncology. Patient 2's medical record showed the patient was admitted to the hospital on 8/25/24.

Review of Patient 2's medical record showed the patient had a NG tube inserted on 8/31/24 at 1745 hours.

However, review of Patient 2's medical record did not show the RN had irrigated the patient's NG tube at least once per shift (on the night shift) on 9/1 and 9/3/24.

On 9/4/24 at 1122 hours, Patient Safety Lead RN 1 and the Director of MS & Oncology verified the above findings.