HospitalInspections.org

Based on a review of facility documentation and staff interviews, the facility failed to ensure:
a) Each patient was evaluated for pain prior to administering PRN "as needed" pain medication, and that upon administration of such medication, the patient was reevaluated for pain medication effectiveness for 1 (Patient #1) of 10 patients (Patients #1-10).
b) Assessment abnormalities were reported to a higher level of nursing care or practitioner for 1 (Patient #1) of 10 patients (Patients #1-10).
c) A linen change was offered to each patient with regular frequency for 2 (Patients #1 and #6) of 10 patients (Patients #1-10).

Findings were:

a) Facility policy entitled Pain Management - Managing Pain in Adults (excluding Perinatal) Acute Care, effective date 03/01/2017, included the following:
"Assessment:
1. Assessment and evaluation of pain will incorporate the use of a Seton Healthcare-approved pain scale ...
2. Patient self-report is the most valid and reliable measure of pain existence and intensity ..."
6. Patients at high risk for respiratory depression or over-sedation may warrant more frequent reassessment. High risk patients may include:
a. Elderly (greater than 65 years of age)
b. Obese patients ...
c. Diagnosis or suspected diagnosis of Obstructive Sleep Apnea..."
8. Reassess pain levels to ascertain effectiveness and safety after administering a sedating pain medication ...
2. Recommend reassessment time intervals: Reassessment is to occur at a minimum of one hour after administration of a medication for pain or discomfort ...
3. Reassessment documentation to include patient response to the medication ..."

Patient #1 was a 69-year-old male with multiple co-morbidities admitted to the hospital for a left total knee arthroplasty on 3/24/17. On 3/25/17, one day post-operative, he reported his pain level at 7 of 10 (10=worst pain imaginable) at 3:13 p.m. There was no documented intervention to address that pain, and his pain level was not re-assessed until 9:00 p.m. that evening. He did receive PRN (as needed) Dilaudid .6 mg IV push at 7:45 p.m., but there is no assessment of his pain level prior to the administration of that pain medication. After the administration of that medication, his pain level was reassessed at 8:45 p.m., with the statement that the medication was "effective." At 9:00 p.m. - 15 minutes later - his pain was re-assessed and he rated it a 9 of 10. At 9:35 p.m. the patient received an additional dose of Dilaudid .6 mg IV push.

On 3/26/17 at 1:50 a.m., Patient #1 was administered .6 mg Dilaudid IV push. The medication was ordered to be administered PRN (as needed). There was no pain assessment documented since the 9:00 p.m. pain rating of 9, for which the patient had already received pain medication at 9:35 p.m. At 5:26 a.m. that same morning, the patient was administered qty. #2 PRN Percocet 7.5/325 mg tablets. There was no documented pain assessment prior to the administration of this "as needed" pain medication dose. At 6:26 a.m., the pain level of Patient #1 was reassessed. It was documented as "not effective." There was no further documentation regarding what symptoms the patient still had or at what level he still rated his pain. The Medication Response form included only "Medication Effective: No." At 7:45 a.m., his pain was reassessed and found to be acceptable.

On 3/26/17 in the afternoon at 3:41 p.m., the patient rated his pain at a level 8 of 10 post-physical therapy. No intervention or further reassessment of his pain was documented until 9:00 p.m. that evening. At that time, Patient #1 rated his pain as a 4 of 10.

The above issues are only examples of pain assessment, reassessment and intervention inconsistencies either in practice or documentation for Patient #1 from 3/25/17 through 3/27/17.

All the above issues were confirmed and discussed during a review of the medical record of Patient #1 on the afternoon of 11/1/17 with Staff #2, Site Quality Coordinator.

b) Facility policy entitled Assessing Reassessing a Patient, effective date 12/23/2014, included the following:
"5. Reassessment Process ...
The reassessment process includes:
a. Patient's response to care ...
6. The physician is notified if any abnormal assessment is evident ..."

Patient #1 was a 69-year-old male with multiple co-morbidities admitted to the hospital for a left total knee arthroplasty on 3/24/17. He was prescribed and being administered pain medication. On 3/26/17, his diastolic blood pressure was found to be below the acceptable normal range for the hospital upon four instances. The times of abnormal readings were: 4:16 a.m., 7:28 a.m., 4:12 p.m. and 8:16 p.m. For example, at 7:28 a.m. his blood pressure was 114/49. It was not retaken until 4:12 p.m. when it was 101/47. The next reading at 8:16 p.m. was 106/48. All of these assessments indicated the diastolic blood pressure to be below the acceptable range. There was no documented evidence available in the medical record of Patient #1 that either a registered nurse or physician had been informed of these abnormal readings.

The above issues were confirmed and discussed during a review of the medical record of Patient #1 on the afternoon of 11/1/17 with Staff #2, Site Quality Coordinator.

c) The medical record of Patient #6 included no documentation of bed linens having been changed at any point during his stay. He was admitted to the hospital on 10/27/17 - 4 days earlier. Patient #1 was admitted on 3/24/17. A bed linen change was offered to Patient #1 on 3/27/17. The offer was declined. The facility could provide no other documented evidence of bed linens having been changed between the date of the patient's admission and 3/28/17 when he was transferred to ICU.

All the above issues were confirmed and discussed during a review of the medical record of Patient #1 on the afternoon of 11/1/17 with Staff #2, Site Quality Coordinator.