HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 1 (Pt. #1) record reviewed, the Hospital failed to ensure staff performed pre and post medication administration reassessments as required by policy.

Findings include:

1. The Hospital policy titled, "Pain Assessment & Management: Adult & Pediatric" (revised 7/1/10) required, Pain is assessed in all patients and response to pain management intervention is monitored. ...Frequency of re-assessment will be increased, as needed, for reasons, such as patient condition, presence of pain or pain treatment modality...Patients will be monitored for their response to pain relieving interventions... documented on the Patient flowsheet and/or the progress record...."

2. The clinical records for Pt. #1 were reviewed on 9/24/13. Pt. #1 was a 73 year old female with two admissions on 5/18/13 to 6/6/13 with a diagnosis of gastro-intestinal (GI) bleed; and on 6/23/13 to 7/2/13, with a diagnosis of atrial fibrillation . Pt. #1 underwent an exploratory laparotomy, lysis of adhesions, removal of mesh, subtotal colectomy and ileoproctostomy surgery on 5/19/13. The clinical records for both admissions indicated Pt. #1 was given pain medications (Morphine or Tylenol) without pre or post medication administration reassessments. Examples are as follows:
-5/24/13 at 2:00 AM, 6:00 AM, 3:40 PM, 6:06 PM, Pt. #1 received 1 mg Morphine, without pre or post pain assessments.
-5/25/13 Pt. #1 received 1 mg Morphine at 1:00 AM for a pre-assessment of 5/10 intensity, with no post medication reassessment; at 3:30 PM, 1 mg Morphine, and 7:59 PM, 2 mg Morphine without pre and post medication pain reassessments.
-6/25/13 at 6:46 PM and 9:59 PM- Pt. #1 received 2 mg Morphine, without pre and post pain reassessments.
6/26/13 at 2:05 AM, Pt. #1 received 2 mg Morphine, and at 12:10 PM, Tylenol with codeine (T3), without pre or post reassessments.

3. The above findings were confirmed with the The Director of Critical Care, interviewed on 9/26/13 at approximately 11:00 AM who stated that pain assessments and reassessments should be performed and documented with each pain medication administration.

Based on document review and interview, it was determined that for 1 of 1 physician (E #4) assessing a surgical wound, the Hospital failed to ensure documentation of the assessment.

Findings include:

1. The hospital policy titled "Assessment of Patients' (revised 6/13), required, "...Reassessment will be performed, ...to determine efficacy or treatment or to identify additional needs when the patient's condition or diagnosis changes. Reassessments are documented whenever there is :...a significant change in patient's condition or status...minimally , progress notes/reassessment are authored by: physician at least daily."

2. The clinical record of Pt. #1 was reviewed on 9/24/13. Pt. #1 was a 73 year old female admitted on 5/18/13 for gastrointestinal bleeding. Pt. #1 underwent an exploratory laparoscopy on 5/19/13 performed by MD #2. The Nursing assessment dated 5/22/13 at 12:41 PM indicated the wound was unapproximated (an opening somewhere in the wound) and "staples have one area at the top of incision where there is a gap of skin, the edges aren't approximated" and a physician (MD #4) was "at bedside to look at the drainage and incision". However the clinical record lacked documentation of the wound assessment by MD #4. Other physician's notes on 5/22/13 and 5/23/13 did not address the opening on the surgical wound. Pt. #1 returned to surgery on 5/24/13 for closure of abdominal wound due to wound dehiscence/bowel evisceration.

3. An interview with MD #2 was conducted on 9/25/13 at approximately 10:30 AM. MD #2 indicated that during examination of the wound he discovered a bowel evisceration, he described as a small opening (would not elaborate further). MD #2 stated he returned Pt. #1 to surgery to close the evisceration on 5/22/13. MD #2 stated that he would expect to be notified if another physician examined the wound and found an evisceration prior to his (MD# 2) own finding.

4. The Director of Performance Improvement interviewed on 9/26/13 at approximately 12:00 PM indicated she was unable to find any documentation of the wound examination by the physician (E #4).