HospitalInspections.org

Based on record review, staff interview and review of medical staff bylaws it was determined the facility failed to ensure bylaws regarding an updated history and physical being in the medical record was implemented for 1 (#9) of 10 sampled patients. This practice does not ensure pertinent medical information is available for the care team.

Findings include:

Patient #9 was admitted to the facility on 1/9/13 for spinal surgery. Review of the history and physical revealed it was dictated on 1/3/13, 6 days prior to the admission. There was no update noted on the history and physical form.

Review of the medical staff bylaws revealed the requirement that if the history and physical is performed within 30 days prior to admission an update must be documented within 24 hours of admission.

During the record review on 1/10/13 the Clinical Nurse Coordinator confirmed the physician failed to update the history and physical as required by the bylaws.

Based on record review and staff interview it was determined the registered nurse failed to supervise and evaluate care related to assessments and interventions for pain management, propofol sedation and use of restraint for 3 (#1, # 3, #10) of 10 sampled patients. This practices does not ensure patient care goals are met.

Findings include:

The facility's policy "Pain Management" #2.600.154 revised 11/12 requires the responsibility of the nurse is to assess the patient, medicate the patient according to his/her self-report, assess the effectiveness of the pain relief measures and obtain orders for additional pain medication if needed. The policy states that a score of 4 or more is considered inadequate pain control. The patient is to be reassessed within one hour after the pain relieving intervention.

1. Patient #1 was admitted on 9/11/12 with the chief complaint of abdominal pain. The Emergency Department (ED) physician's clinical impression was pancreatitis. Review of pain assessment documentation by nursing revealed the patient reported the pain level to be 10 on a 0-10 pain scale at 5:10 p.m. Review of the Medication Administration Record (MAR) revealed the patient received Dilaudid 2 milligrams (mg) intravenously (IV) at 5:10 p.m. The reassessment at 5:47 p.m. revealed the pain had been relieved with the patient reporting a pain level of 1.

The pain assessment documented at 6:30 revealed the pain level was at 10. Two mg of Dilaudid was administered at 6:35 p.m. according to the MAR. The next assessment at 7:40 p.m. revealed a pain level of 8. Review of the MAR revealed no pain medication was administered. There was no evidence the physician was notified that the medication given at 6:35 p.m. was not effective. The patient was not assessed for pain again until 9:50 p.m., over three hours later. The patient reported the pain level at 9 on the 0-10 pain scale. The next assessment documented at 1:50 a.m. on 9/12/12 revealed the pain level was reported as 7. The patient received two mg of Dilaudid at 2:09 a.m. At 3:09 a.m., the pain level was documented as 2. The next pain assessment was documented at 7:25 a.m. with the level being reported at 8. No pain medication was administered. The next assessment at 9:09 a.m. revealed the pain level was now 9 on the 0-10 scale. The MAR revealed 1 mg of Dilaudid was administered. The reassessment at 9:46 a.m. revealed the pain level at 3. On 9/13/12 at 4:46 a.m. the nurse documented the patient reported pain at 10. Dilaudid 2 mg was administered. Reassessment at 5:19 a.m. revealed the pain level was still 10. Reassessment at 5:32 a.m. revealed the pain level was still unacceptable at 6. There was no documentation that the physician was notified that the Dilaudid was not effective and no additional medication was administered. Pain management was not implemented by nursing per policy.

2. Patient #3 was admitted on 1/7/13 with the diagnosis of lung cancer. Review of the pain assessments by nursing revealed the patient reported pain as a level 6 on 1/8/13. Review of the MAR revealed no pain medication was administered at that time. The next assessment at 11:45 a.m. revealed the pain level was 7. Vicodin was administered at 11:45 a.m. The reassessment at 12:40 p.m. revealed a pain level of 2. There was no explanation documented for the delay in providing the necessary pain medication.

3. Patient #10 was admitted on 1/7/13 with acute pancreatitis. Review of pain assessments documented by nursing revealed on 1/8/13 at 6:10 a.m. the patient reported pain as a 6 on the 0-10 scale. Further review of nursing documentation revealed no reassessment of the pain level within an hour as required by facility policy.

The Clinical Nurse Coordinator, who was present during the record reviews on 1/9/13 and 1/10/13, confirmed the above findings for patients #1, #3 and #10.



Review of the facility's policy "Propofol Infusion for Adult Patients" #2.712.008 revised 1/12 requires the nurse assess the level of sedation every 4 hours while the propofol is infusing.

1. Patient #1 was intubated and placed on a ventilator on 9/15/12. An order for propofol for sedation was written by the physician. According to documentation the Propofol was infusing from 9/19-9/25/12 at 3:53 p.m. Review of nursing documentation revealed no documentation of monitoring of the level of sedation on 9/19, 9/20, 9/21, 9/22, 9/23 and 9/24/12 between the hours of 4:00 a.m. and 8:00 p.m.

The Critical Care nursing director and nursing manager were asked to review the above findings on 1/10/13 at approximately 9:00 a.m. They indicated that most likely at least some of that time the propofol had been discontinued as the patient was being weaned from the ventilator but could not locate documentation to substantiate that. The documentation revealed the assessment for the level of sedation as required by the facility's policy was not performed by nursing.



Review of the facility's policy "Patient Restraint and Seclusion" #2.600.049 revised 8/12 requires that physician's order include the duration of restraint and date and time of the order.

1. Review of the restraint orders for patient #1 revealed the initial order was written on 9/16/12 at 10:50 a.m. The duration of restraint was 24 hours. The next order was not written until 9/17/12 at 8:00 p.m., which was approximately nine hours after the first order had expired.

Orders were written on 9/18/12 and 9/19/12 but the time of the order was not included. The last order was written on 9/24/12 at 7:00 a.m. Review of documentation of restraint monitoring revealed the restraint was maintained from 9/16/12 until 9/25/12 at noon. The restraint order had expired at 7:00 a.m. on 9/25/12. The restraint was continued for 5 hours after the order had expired.

The Clinical Nurse Coordinator, who was present during the record review on 1/9/13, confirmed the nursing staff did not follow the facility's policy.