HospitalInspections.org

Based upon policy and procedure review, observation during tours, patient, staff and physician interviews, and open and closed medical record review, the nursing staff failed to assess patient's pain goal upon admission and follow pain assessment policy for 1 out of 3 patients (#3).

The findings include:

Review of the hospital's policy "Clinical: General Care of the Inpatient" with approval date of 10/23/2014 revealed "Assessment: Upon arrival to an inpatient nursing unit, an initial patient assessment will be performed as appropriate based on patient age and condition. At a minimum, this assessment will include:
......7. A head-to-toe physical and psychological assessment. This will include, at a minimum: a. Cognition/Mentation (LOC (level of consciousness), speech, pain)......Within 24 hours of admission, an assessment of the patient's risks and needs will be performed, and will include:....6. Chronic pain...."

1. Closed medical record of patient #3 on 04/14/2016 revealed a 20 year old female admitted on 03/25/2016 from home with nausea and vomiting. Review of history and physical dated 03/26/2016 revealed Pt #3 had same day surgery of uncomplicated laparoscopic cholecystecomy on 03/23/2016 (surgical removal of the gallbladder through small incisions in the abdomen). Further review revealed Pt #3 reports severe pain and nausea since surgery and was admitted with intractable pain and nausea.

Review of electronic admission assessment dated 03/25/2016 revealed plan of care pain goal is left blank throughout patient's hospital stay. Further review revealed Pt #3 left AMA (against medical advice) on 03/27/2016 after complaints of pain is not being relieved.

Interview with RN #1 on 04/14/2016 at 1000 revealed "Patient goal assessment is subjective. It is patient's words. It shouldn't be skipped."

Interview with AS #1 on 04/14/2016 at 0945 revealed the admission assessment of the pain goal should be completed. "It is part of the admission assessment and it is expected to be completed." Interview revealed policy was not followed for completing the admission pain goal.



2. Review of policy "Pain Management" dated 09/29/2015 revealed "All patients will be assessed for the presence of pain upon admission and as needed, based upon the patient's age and condition. This assessment shall include the patient's description of 1. The severity of the pain utilizing one of the following appropriate pain scales: a. Numeric Scale (0-10) for verbal adults....."

Closed medical record of patient #3 on 04/14/2016 revealed a 20 year old female admitted on 03/25/2016 from home with nausea and vomiting. Review of history and physical dated 03/26/2016 revealed Pt #3 had same day surgery of uncomplicated laparoscopic cholecystecomy on 03/23/2016 (surgical removal of the gallbladder through small incisions in the abdomen). Further review revealed Pt #3 reports severe pain and nausea since surgery and was admitted with intractable pain and nausea. Review of physician orders dated 03/25/2016 at 0925 revealed Morphine 1-4 mg IV every 1 hrs prn pain (narcotic with dose of 1 to 4 milligrams to be given every 1 hours as needed for pain). Review of MAR (medication administration record) dated 03/26/2016 at 0837 through 03/27/2016 at 1123 of reassessments of pain medicine administration revealed no documentation of pain effectiveness using pain scale. Further review revealed documentation of medication effectiveness as "partially met" or "partially effective." Further review revealed Pt #3 left AMA (against medical advice) on 03/27/2016 after complaint of pain not being relieved.

Interview with RN #1 on 04/14/2016 at 1000 revealed "I was taught to write both pain scale and verbatim of the patient." Further interview revealed the nurse should document the number of the patient's pain response.

Interview with AS #2 on 04/14/2016 at 1100 revealed pain reassessments should be documented using the universal pain scale. "Our policy refers to the Lippincott which uses pain scale numbers." Further interview revealed policy was not followed which requires using pain scale numbers with pain reassessments.

Based on closed medical record review and staff interviews, the nursing staff failed to provide education on Foley catheter care at discharge for 1 of 1 patient being discharged to home with a Foley catheter. (patient #8)

Record review revealed patient #8 was admitted to named hospital on 3/15/16 with diagnoses of sepsis (bacterial infection in the bloodstream) and a urinary tract infection (infection of the urinary bladder), and was discharged on 3/31/16 to home.
Closed record review of patient #8 admission history and physical documented by MD #5 revealed "...HISTORY OF PRESENT ILLNESS...she has a chronically indwelling Foley catheter (tube into the bladder to drain urine into a collection bag), which was changed out 4 days ago..."
Record review revealed the Foley catheter remained in place during the entire hospitalization, and the patient was discharged to home with the catheter in place. Review of the discharge instructions dated 3/31/16 at 1325, and signed by the patient's spouse (caregiver), revealed an education teaching sheet titled "URINARY TRACT INFECTION Care of a Urinary Tract Infection (UTI)".
Further record review failed to reveal education to the spouse regarding care of a Foley catheter. Interview with RN #1 on 4/14/15 at 1330 confirmed there was no documentation of Foley catheter education, and that there was no Foley catheter education in the discharge instructions given to the spouse on 3/31/16.