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Based on observation, interview and record review, the facility's nursing staff failed to evaluate patient's condition while receiving care in 1 of 3 sampled patients. # Patients 1,2 & 7

Findings:


Patient #1

An interview was made by the Surveyor with Patient #1 by telephone on 10/08/2015 at 4:11 p.m. revealed that she verified the contents of the complaint details filed to the State Agency as stated on Intake #TX00222394. Patient #1 said "All what I have written about my stay at this Facility were all true, they gave me pain medicine at the back room where other people could see me; no staff would even come to check me how I was doing after giving the medicine in my vein."

Review of Patient #1 closed Medical Records revealed that she came to the Emergency Room on 05/10/2015 due to abdominal pain; a Medical Screen Exam performed at 10:00 a.m. an initial pain assessment performed at 11:01 a.m. by Staff RN (11). Staff RN (11) administered Morphine 4 mg/ml via IV or Intravenous at 11:31. A pain reassessment record noted while in Emergency Room at 13:40.

Patient #1 was admitted in the afternoon of on 05/10/2015 at 15:49. A medication. Morphine 4mg IV was given at 20:35 with a Pain Score of 10/10; location is Abdomen, no pain reassessment noted in the Pain Monitor sheet, the next pain assessment was done on 05/11/2015 at 05:54 a.m. with a pain score of 8 out 10 in the abdomen that says "Pre-medication" no immediate pain reassessment noted.


Patient #2


Review of Patient #2 closed Medical Records revealed that she came to the Emergency Room on 05/10/2015 due to abdominal pain; a Medical Screen Exam performed at 03:31 a.m. an initial pain assessment performed at 04:50 a.m. by Staff RN (10). Staff RN (12) administered Morphine 4 mg/ml via IV or Intravenous. No further pain assessment record noted while in Emergency Room.


Patient #7


Interviewed Patient #7 in room #7 on 10/08/2015 at 2:15 p.m., the Surveyor asked her comfort level while receiving care in the Emergency facility, she said "My nurse is horrible, I had to call her and ask for pain reliever every time, nobody even comes to check how am I doing since this morning. My vital signs were not checked, and I have been awake since this morning; I do not know what are they waiting?" At 2:25 p.m., while Surveyor was talking outside with Staff RN (7), Patient #7 came-out of her room and talked with the staff at the Nurses' station asking for her nurse.


Review of Patient #7 Medical Records while at the bedside revealed that she came to the Emergency Room on 10/08/2015 due to stomach ache; a Medical Screen Exam performed at 06:36 a.m. The second dose of Morphine 2mg/ml via Intravenous was given at 10:51 a.m. while a third dose of Morphine at 13:11 no pain reassessment noted in her medication records.

An interview was made on 10/08/2015 at 2:20 p.m., with a Unit RN (7) the Surveyor verified with her about visit documentation related to pain of Patient #7, she said "I had no chance because I also was attending with my other patients, but will document later. She had total of like 6 pain medicines already."

An interview was made on 10/08/2015 at 3:35 p.m., with a Unit RN (8) that helped the Surveyor in doing the record reviews, she confirmed no immediate reassessment was made for Patients 1, 2, and 7 after receiving their medications for pain based on the documents provided to the Surveyor.

An interview was made on 10/08/2015 at 4:20 p.m., with the Facility Quality Vice President (1) the Surveyor verified with her about the missing documentations related to pain of Patients 1,2, & 7, she said "We have plan of doing an hourly audit including pain in the Emergency department but it has not been implemented yet."


Review of the facility ' s policy about Assessment/Reassessment: Pain Management Guidelines: HCA Gulf Coast Division # 600.100.016 on page 3 item 2 " Reassessment (30 minutes after IV meds, 60 minutes after po meds) of Pain Intensity, Location, Quality of Pain, Onset, duration, variation, patterns, Alleviating and Aggravating Factors."