HospitalInspections.org

Based on medical record review, interview, and document review, it was determined that the facility:

failed to document pain reassessment scores for three (3) out of four (4) patient medical records reviewed (Patient #2, #3 and #4),

failed to provide medications or other interventions once a patient's pain assessment score was determined for two (2) of four (4) patient records reviewed (Patient #2, Patient #3), and;

failed to provide daily hygiene and comfort measures for one (1) of four (4) patient records reviewed (Patient #2).

Findings:

Pain Reassessment

A review of the facility's policy entitled, "Pain Management," effective date January 27, 2022, revision 1.0, states in part:
..." Policy
... J. Team members assess, reassess and respond to the patient's pain through the following:
J.1. Evaluation and documentation of response(s) to pain intervention(s)
J.2. Progress toward pain management goals ....
... 4. Post-intervention assessment
4.1 Criteria
4.1.1 Following each intervention, evaluate the response based on the patient's ability to perform ADL's [activities of daily living]/achieve functional goals, and adequate comfort.
4.1.2. Select appropriate pain assessment scale for age, condition, and ability to understand.
... 4.2 When to assess
... Location
... Inpatient ....
Post Intervention Assessment
1. Perform the post intervention assessment based on anticipated time of response of the medication or the intervention."

The facility's policy entitled, "Medication Administration," document number PH.AD.009, effective date July 30, 2021, revision 3.2, states in part:
... "Definitions
Term:
... Administration Time - PRN
Designation for medication orders that are to be administered on an as needed basis according to the medication order's indication, patient's response, and/or timing of clinical situation."

The document provided by the facility and referenced in policy, titled "Pain assessment," from Lippincott Nursing Procedures and Skills reads, in part:
... "Reassessment of pain at designated intervals according to the type of pain intervention (for example, oral, IV [intravenous], or transdermal route) is necessary to evaluate progress toward pain management goals."

The medical record for Patient #2 revealed that the patient's pain was not documented as reassessed within the anticipated time of response after pain medications were administered for fifty-four (54) out of eighty-five (85) pain medication administrations, as follows: (ER = Extended Release; IR = Immediate Release; PO = orally; IV = intravenously)

September 12, 2024
Hydromorphone 1 mg IV, administered at 12:54 AM, Pain reassessed over three (3) hours later at 4:00 AM.
Hydromorphone 1 mg IV, administered at 5:22 PM, Pain reassessed over fourteen (14) hours later at 8:06 AM.
Oxycodone IR 15 mg PO, administered at 6:06 PM, Pain reassessed over fourteen (14) hours later at 8:06 AM.
Oxycodone IR 15 mg PO, administered at 10:08 PM, Pain reassessed ten (10) hours later at 8:06 AM.

September 13, 2024
Hydromorphone 1 mg IV, administered at 1:28 AM, Pain reassessed over six (6) hours later at 8:06 AM.
Oxycodone IR 15 mg PO, administered at 2:14 AM, Pain reassessed over five (5) hours later at 8:06 AM.
Oxycodone ER 10 mg PO, administered at 11:37 AM, Pain reassessed over eight (8) hours later at 7:43 PM.
Oxycodone IR 15 mg PO, administered at 3:47 PM, Pain reassessed over four (4) hours later at 7:43 PM.
Oxycodone ER 10 mg PO, administered at 9:26 PM, Pain reassessed over two (2) hours later at 11:40 PM.

September 14, 2024
Oxycodone IR 15 mg PO, administered at 1:24 PM, Pain reassessed over three (3) hours later at 4:23 PM.
Oxycodone ER 10 mg PO and Oxycodone IR 15 mg PO, administered at 8:43 PM, Pain reassessed over three (3) hours later at 12:00 AM.

September 15, 2024
Oxycodone IR 15 mg PO, administered at 4:40 AM, Pain reassessed over four (4) hours later at 9:00 AM.
Hydromorphone 0.4 mg IV, administered at 6:04 AM, Pain reassessed three (3) hours later at 9:00 AM.
Hydromorphone PCA 0.6 mg, administered at 12:37 PM, Pain reassessed over two (2) hours later at 2:36 PM.
Hydromorphone PCA 0.6 mg, administered at 8:25 PM, Pain reassessed over seven (7) hours later at 4:00 AM.
Oxycodone ER 10 mg PO and Hydromorphone PCA 0.6 mg, administered at 9:25 PM, Pain reassessed over six (6) hours later at 4:00 AM.

September 16, 2024
Hydromorphone PCA 0.6 mg, administered at 12:45 AM, Pain reassessed over three (3) hours later at 4:00 AM.
Hydromorphone PCA 0.6 mg, administered at 8:00 AM, Pain reassessed four (4) hours later at 12:00 PM.
Oxycodone ER 10 mg PO, administered at 9:30 AM, Pain reassessed over two (2) hours later at 12:00 PM.
Oxycodone IR 10 mg PO, administered at 5:36 PM, Pain reassessed five (5) hours later at 10:32 PM.
Oxycodone ER 10 mg PO, administered at 10:32 PM, Pain reassessed over two (2) hours later at 1:00 AM.

September 17, 2024
Hydromorphone 1 mg IV, administered at 9:03 AM, Pain reassessed over three (3) hours later at 12:32 PM.
Oxycodone ER 10 mg PO, administered at 9:48 AM, Pain reassessed over two (2) hours later at 12:31 PM.
Oxycodone IR 10 mg PO, administered at 3:02 PM, Pain reassessed over five (5) hours later at 8:25 PM.
Oxycodone IR 10 mg PO and Oxycodone ER 10 mg PO, administered at 8:26 PM, Pain reassessed over twelve (12) hours later at 8:36 AM.
Oxycodone IR 10 mg PO, administered at 11:58 PM, Pain reassessed over eight (8) hours later at 8:36 AM.

September 18, 2024
Oxycodone IR 10 mg PO, administered at 6:25 AM, Pain reassessed over two (2) hours later at 8:36 AM.
Oxycodone ER 10 mg PO, administered at 8:39 AM, Pain reassessed over three (3) hours later at 12:14 PM.
Hydromorphone 1 mg IV, administered at 12:24 PM, Pain reassessed over four (4) hours later at 4:47 PM.
Oxycodone IR 10 mg PO, administered at 6:56 PM, Pain reassessed over two (2) hours later at 9:27 PM.
Oxycodone IR 10 mg PO, administered at 11:23 PM, Pain reassessed over six (6) hours later at 6:06 AM .

September 19, 2024
Oxycodone IR 10 mg PO, administered at 3:53 AM, Pain reassessed over two (2) hours later at 6:06 AM.
Hydromorphone 4 mg PO, administered at 4:34 PM, Pain reassessed over three (3) hours later at 8:29 PM.
Oxycodone ER 10 mg PO, administered at 9:33 PM, Pain reassessed over five (5) hours later at 3:21 AM.
Hydromorphone 2 mg PO, administered at 11:03 PM, Pain reassessed over four (4) hours later at 3:21 AM.

September 20, 2024
Hydromorphone 2 mg PO and Oxycodone ER 10 mg PO, administered at 8:49 AM, Pain reassessed over four (4) hours later at 1:17 PM.
Oxycodone ER 10 mg PO, administered at 8:54 PM, Pain reassessed over four (4) hours later at 1:00 AM.

September 21, 2024
Hydromorphone 2 mg PO, administered at 1:40 AM, Pain reassessed over two (2) hours later at 4:30 AM.
Hydromorphone 2 mg PO, administered at 5:35 AM, Pain reassessed over two (2) hours later at 8:00 AM.
Oxycodone ER 10 mg PO, administered at 9:11 AM, Pain reassessed six (6) hours later at 3:10 PM.
Hydromorphone 2 mg PO, administered at 12:39 PM, Pain reassessed over two (2) hours later at 3:10 PM.
Oxycodone ER 10 mg PO, administered at 9:13 PM, Pain reassessed over three (3) hours later at 12:35 AM.

September 22, 2024
Hydromorphone 2 mg PO, administered at 12:28 AM, Pain reassessed over three (3) hours later at 3:50 PM.
Hydromorphone 2 mg PO, administered at 6:14 AM, Pain reassessed over three (3) hours later at 9:15 AM.
Oxycodone ER 10 mg PO, administered at 9:17 AM, Pain reassessed over three (3) hours later at 12:20 PM.
Hydromorphone 2 mg PO, administered at 5:44 PM, Pain reassessed over four (4) hours later at 10:07 PM.
Hydromorphone 2 mg PO, administered at 10:02 PM, Pain reassessed over three (3) hours later at 1:01 AM.

September 23, 2024
Hydromorphone 2 mg PO, administered at 4:02 AM, Pain reassessed over four (4) hours later at 8:02 AM.
Oxycodone ER 10 mg PO and Hydromorphone 2 mg PO, administered at 8:40 AM, Pain reassessed over four (4) hours later at 1:00 PM.
Oxycodone ER 10 mg PO, administered at 9:53 PM, Pain reassessed over ten (10) hours later at 8:00 AM.
Hydromorphone 2 mg PO, administered at 10:51 PM, Pain reassessed over nine (9) hours later at 8:00 AM.

September 24, 2024
Hydromorphone 2 mg PO, administered at 2:21 AM, Pain reassessed over five (5) hours later at 8:00 AM.
Hydromorphone 2 mg PO, administered at 5:03 PM, Pain reassessed over three (3) hours later at 8:45 PM.

September 25, 2024
Hydromorphone 2 mg PO, administered at 1:14 AM, Pain reassessed over two (2) hours later at 3:49 AM.

The medical record for Patient #3 revealed that the patient's pain was not documented as reassessed within the anticipated time of response after pain medications were administered for eight (8) out of eleven (11) pain medication administrations, as follows:

September 11, 2024
Oxycodone IR 5 mg PO, administered at 1:50 PM, Pain reassessed over ten (10) hours later at 12:00 AM.
Oxycodone IR 5 mg PO, administered at 10:07 PM, Pain reassessed almost two (2) hours later at 12:00 AM.

September 12, 2024
Oxycodone 10 mg PO, administered at 8:21 AM, Pain reassessed over four (4) hours later at 12:32 PM.

September 13, 2024
Oxycodone 10 mg PO, administered at 12:25 AM, Pain reassessed over eight (8) hours later at 7:53 AM.
Oxycodone IR 5 mg PO, administered at 12:33 PM, Pain reassessed over two (2) hours later at 2:37 PM.

September 14, 2024
Oxycodone IR 5 mg PO, administered at 6:08 AM, Pain reassessed almost two (2) hours later at 8:04 AM.
Oxycodone IR 5 mg PO, administered at 2:38 PM, Pain reassessed over seven (7) hours later at 9:57 PM.

September 15, 2024
Oxycodone IR 5 mg PO, administered at 10:33 AM, There was no documented reassessment of pain.

The medical record for Patient #4 revealed that the patient's pain was not documented as reassessed within the anticipated time of response after pain medications were administered for four (4) out of six (6) pain medication administrations, as follows:

September 10, 2024
Fentanyl 25 mcg IV, administered at 12:52 PM, Pain reassessed over two (2) hours later at 3:15 PM.
Fentanyl 25 mcg IV, administered at 3:56 PM, Pain reassessed over four (4) hours later at 8:36 PM.
Fentanyl 25 mcg IV, administered at 8:50 PM, Pain reassessed over five (5) hours later at 2:16 AM.

September 11, 2024
Fentanyl 25 mcg IV, administered at 2:15 AM, Pain reassessed over six (6) hours later at 8:25 AM.

During an interview on November 4, 2024, at 2:16 PM, Staff Member #10 indicated that nurses should assess a patient's pain level before any pain medication is given and then perform a post intervention assessment fifteen (15) to thirty (30) minutes after an intravenous (IV) medication is administered, or within one (1) hour after an oral medication is given, based on the time of the anticipated response to the medication. The patient's reported pain level would indicate whether the medication intervention provided was sufficient to control the patient's pain. All pain assessments and reassessments are expected to be documented in the patient's flowsheet. Staff Member #10 revealed that the facility's electronic medical record (EMR) system, prompts the nurse to perform a pain reassessment one (1) hour after any medication has been administered, but the prompt may be "skipped" by the nurse.

During an interview on November 6, 2024, at 9:45 AM, Staff Member #14 indicated that the expectation is that the nurse performs reassessments of the patient's pain after medication administration and logs that value into the flowsheet. "I would hope a nurse would go back and reassess" within at least one (1) hour but there is "nothing in writing" stating the specific time frame. Staff Member #14 indicated that a reminder appears in the EMR for a nurse to reassess pain after administration of a pain medication, but the nurse can skip or ignore the reminder.

Interventions

The facility's policy titled, "Pain Management," effective date January 27, 2022, revision 1.0, reveals:
... 3. Interventions
3.1 The nurse collaborates with the provider to obtain orders for an appropriate medication or other multimodal method (including type, route, frequency of administration and duration) based on the pain assessment and severity of pain.
3.2 The nurse collaborates with the provider to adjust pharmacologic dosing ....
3.4 Consider consultation and/or referral for patients experience persistent pain, complex pain management needs, pain management needs which exceed provider expertise, high potential for adverse effects or risk related to opioids, or who exhibit signs of substance abuse disorder or psychological distress ....
5. If pain is interfering with treatment goals, or pain interventions are ineffective, notify provider.
6. Document results of screenings, assessments, interventions, and progress towards goals in the electronic health record."

The medical record for Patient #2 revealed that the patient did not have any documented pain medication or other interventions performed after a documented pain score of seven (7) out of ten (10) or higher, indicating severe pain, in thirty-four (34) out of seventy-four (74) documented pain scores.

During an interview on November 4, 2024, at 11:06 AM, Staff Member #4 indicated that there were no nurses' notes addressing the patient's pain, consults or referral for pain, or physician documentation related to pain management in Patient #2's medical record.

During an interview on November 4, 2024, at 1:17 PM, Staff Member #5 indicated that a patient request for additional pain medications, outside of scheduled dosages or PRN ordered dosages, should be documented in the flowsheet and the nurse should contact the provider to request additional pain medications if requested.

During an interview on November 4, 2024, at 2:16 PM, and on November 6, 2024, at 9:30 AM, Staff Member #10 and Staff Member #13, respectively, indicated if a patient had received a pain medication and was still experiencing pain after the anticipated time of response, the nurse should contact the provider for other additional interventions, depending on the severity of the pain. That intervention may include additional pain medication, or another intervention, such as repositioning the patient. All interventions should be documented on the patient's flowsheet.

Daily Hygiene and Comfort Measures

The facility's document titled "Daily Adult Patient Treatment and Cleansing Algorithm," reveals:

If a patient does not have a Chorhexidine Gluconate (CHG) allergy, "use at least 6 [six] CHG for neck down CHG treatment." Peri care [perineal care] and foley care [urinary catheter] should be performed "daily with CHG wipes and after episodes of stool incontinence. Document each task (peri care and foley care) separately when completed."

The facility's document titled "Competency: Adult Chlorhexidine (CHG) Bath Treatment," updated October 7, 2020, states in part that staff are expected to perform CHG baths for those patients unable to cleanse themselves. The document states that the staff member must, "demonstrate proper technique for completing a CHG treatment and verbalizes knowledge of the important role daily CHG treatments play in preventing hospital acquired infections."

The medical record for Patient #2 revealed no documentation of a bath for four (4) out of fourteen (14) days the patient was on the neurology unit, September 14, 21, 23, and 24, 2024.

The medical record for Patient #2 revealed no documentation of a gown change for nine (9) out of fourteen (14) days the patient was on the neurology unit, September 14, 15, 17, 19, 21, 22, 23, 24, and 25, 2024.

The medical record for Patient #2 revealed no bed linen change for ten (10) out of fourteen (14) days the patient was on the neurology unit, September 14, 15, 16, 17, 20, 21, 22, 23, 24, and 25, 2024.

During an interview on November 4, 2024, at 2:10 PM, Staff Member #10 indicated that patients receive CHG baths daily, although patients may receive baths more frequently if the patient is incontinent. The CHG baths should be documented in the flowsheet. Staff Member #10 indicated some patients prefer to shower, but the CHG bath is better for patients while on this unit. Staff Member #10 indicated that linens and gowns are changed when the patient is bathed and more frequently if soiled, and these changes should be documented on the flowsheet as well.

During an interview on November 6, 2024, at 9:30 AM, Staff Member #13 indicated that Patient #2 was totally dependent on all hygiene care. Staff Member #13 indicated that patients should be bathed daily with CHG wipes, have all sheets and their gown changed. These should be documented on the patient's flowsheet.