HospitalInspections.org

Based on policy reviews, closed medical record reviews and staff interviews, the nursing staff failed to assess and/or reassess pain for 2 of 6 sampled medical records reviewed (#4, #5); and failed to provide hygiene care for 2 of 3 sampled medical records reviewed (#4, #5).

The findings include:

A. Review of Hospital Policy titled, "Pain Management", effective date: 06/18/2013, revealed, "...6. Reassessment: a. Frequency: i. Every shift ...if no pain and /or patient satisfied with treatment plan. ii. At a minimum of q 4h (every four hours) if patient not satisfied. iii. Within one 1 hour following any intervention (i.e. scheduled or prn (as needed) analgesia medication, change in treatment plan, or non-pharmacological action)...."

Review of Hospital Policy titled, "Patient Controlled Analgesia", effective date: 06/01/2013, revealed ...Patient controlled analgesia (PCA) is an efficient and effective method of delivering pain medication to patients. An opioid infusion device is programmed to deliver a prescribed amount of medication which the patient 'demands' based upon their level of pain. PCA can be a continuous dosing, and/or an intermittent dose delivered by the patient via the 'button'/pendant... B. Maintenance: ...4. Monitor patient's response to PCA/PCA-HG (higher guardrail) infusion and document on the plan of care and flowsheet: a. ADULT: Pain score, RASS (Richmond Agitation Sedation), and respiratory rate: i. Every 2 hours for the first 24 hours after initiation of PCA. ii. Every 2 hours for subsequent increase in dose. iii. Every 4 hours thereafter until the PCA/PCA-HG is discontinued..."

1. Closed medical record review of Patient #4 revealed a 68 year old male admitted on 03/30/2016 1233 with a diagnosis of colon cancer metastasized to small intestine and was discharged on 04/25/2016 at 1740. Review of physician orders dated 03/30/2016 at 1912 revealed an order for Hydromorphone (Dilaudid) PCA (Patient Controlled Analgesia) 1 mg/ml (milligram/milliliter) continuous with 8 minute lockout interval for 5 days. Review of Medication Administration Record (MAR) from 03/30/2016 at 2219 through 04/03/2016 at 1815 revealed documentation that Patient #4 was on a Continuous PCA infusion of Dilaudid 1mg/1ml from 03/30/2016 at 2219 through 04/03/2016 at 1815. Review of nursing flowsheets for 03/30/2016 through 04/03/2016 revealed documentation of pain assessment by nursing of the patient's response to the Hydromorphone (Dilaudid) PCA therapy on 03/30/2016 at 2219 and 2345, on 03/31/2016 at 0220 (35 minutes late), 0400, 0527, 0852 (85 minutes late), 0904, 1200 (56 minutes late), 1800 (240 minutes late), 2017 (17 minutes late) and 2334 (77 minutes late), on 04/01/2016 at 0422, 0610, 0642, 0800, 1148, 1313, 1330, 1600 and 2000, on 04/02/2016 at 0900 (540 minutes late) and 1220, on 04/03/2016 at 0000 (460 minutes late), 0549 (109 minutes late), 0900 and 1742 (289 minutes late). Further review of Physician's Orders revealed an order on 04/03/2016 at 1815 to discontinue PCA infusion. Review of Physician's Orders revealed an order on 04/03/2016 at 1816 for Dilaudid 0.5 mg (milligrams) IVP (intravenous push) q 3h (every 3 hours) prn (as needed) for breakthrough pain, and on 04/03/2016 at 2350 for Tramadol (narcotic like pain medication) 50 mg po (by mouth) q 4h (every 4 hours) for moderate pain of 4-6 on pain scale and severe pain 7-10 on pain scale. Review of MAR revealed documentation that Tramadol 50 mg was administered on 04/04/2016 at 0040, 0348, 0940, 1401 and 1929. Review of nursing flowsheet for 04/04/2016 revealed documentation of a pain reassessment by nursing of the patient's response to the Tramadol therapy on 04/04/2016 at 0140, 0448, 1100 (20 minutes late), 1450 and 2013. Review of Physician's orders revealed an order on 04/04/2016 at 1959 for Dilaudid 1 mg IVP (intravenous push) once now, on 04/04/2016 at 2317 for Dilaudid 0.5 mg IV once now and on 04/04/2016 at 2327 for Dilaudid 1 mg IVP q 3h prn for breakthrough pain and Tylenol 975 mg po q 6h (every 6 hours) prn (as needed) for fever and pain. Further review of MAR revealed documentation that Dilaudid 1 mg IVP was administered on 04/04/2016 at 2013 and Dilaudid 0.5 mg IVP was administered on 04/04/2016 at 2312 and 2328. Review of nursing flowsheet for 04/04/2016 revealed documentation of a pain reassessment by nursing of the patient's response to the Dilaudid therapy on 04/04/2016 at 2312 (119 minutes late), 2328 and 2342. Review of Physician's Orders revealed an order on 04/05/2016 at 0642 for Dilaudid 1 - 2 mg tablets po q 4 h prn for moderate pain 4-6 on pain scale and severe pain 7-10 on pain scale. Further review of MAR revealed documentation that Toradol 7.5 mg IVP was administered on 04/05/2016 at 0604, 1258 and 1736. Review of nursing flowsheet for 04/05/2016 revealed documentation of a pain reassessment by nursing of the patient's response to the Toradol therapy on 04/05/2016 at 0746 (42 minutes late), 1645 (167 minutes late) and 1745. Further review of MAR revealed documentation that Dilaudid 2 mg po was administered on 04/06/2016 at 1303 and 1929. Review of nursing flowsheet for 04/06/2016 revealed documentation of a pain reassessment by nursing of the patient's response to the Dilaudid therapy on 04/06/2016 at 1929 (326 minutes late) and 2315 (166 minutes late). Further review of MAR revealed documentation that Toradol 7.5 mg IVP was administered on 04/06/2016 at 0056. Review of nursing flowsheet for 04/06/2016 revealed documentation of a pain reassessment by nursing of the patient's response to the Toradol therapy on 04/06/2016 at 0416 (140 minutes late).
Interview with NM (nurse manager) #1 on 04/28/2016 at 1500 revealed nursing staff should reassess a patient's response to a pain intervention within one hour of the administration of pain medication/intervention and document the pain assessment on the nursing flowsheet in the electronic medical record. Interview revealed "We should have reassessed pain within 1 hour after pain medication administered. We should follow hospital pain policy." Interview confirmed there was no pain reassessment documented by nursing staff on the patient's response to Tramadol administered on 04/04/2016 at 0940, Dilaudid administered on 04/04/2016 at 2013 and on 04/06/2016 at 0056, 1303 and 1929, and Toradol administered on 04/05/2016 at 0604 and 1258. Interview confirmed nursing staff did not follow hospital policy for reassessment after pain intervention. Further interview revealed nursing staff should assess for pain every 2 hours and with any increase in rate for the first 24 hours after being placed on a PCA pump and then every 4 hours. Interview revealed "We should follow hospital Patient Controlled Analgesia policy for patients with a PCA pump." Interview confirmed nursing staff did not follow the hospital policy for patients with a PCA pump.
2. Closed Medical Record review of Patient # 5 revealed the patient was admitted on 01/11/2016 with a diagnosis of rectal cancer. Record review revealed that Pt # 5 was placed on a PCA (Patient Controlled Analgesia) for pain on 01/11/2016 at 1402. Review revealed the patient was assessed at least every two hours from 01/11/2016 at 1402 through 01/12/2016 at 0200. After 0200, record review failed to reveal Pt # 5 was reassessed until 0705 (5 hours, 5 minutes later). Further record review failed to reveal evidence that Pt # 5 was reassessed from 01/12/2016 at 0839 until 1202 (3 hours, 23 minutes later). Record review revealed the PCA was discontinued on 01/14/2016 at 1430. Record review revealed Pt # 5 was assessed for pain at 1621 with a pain score of 8 out of 10 and was medicated with Oxycodone (given for pain) 10 mg (milligrams). Review failed to reveal a reassessment in 1 hour. Review revealed the next pain assessment was documented at 1940 (3 hours, 19 minutes). Further record review revealed a pain score of 8 on 01/15/2016 at 0303, with Oxycodone 10 mg given. Review failed to reveal another pain assessment until 0730 (4 hours 27 minutes later).

Interview with Nurse Manager (NM) # 2 on 04/28/2016 revealed there was no additional evidence to indicate pain was reassessed as required. Interview revealed policys was not followed.

B. Review of Hospital Policy titled, "Basic Care of the Hospitalized Patient", effective date: 02/16/2016, revealed, "...1. Frequency of ADLs (activities of daily living) are recommended as following but based upon patient preference, patient tolerance and activities: a. Bathing: daily..."
1. Closed medical record review of Patient #4 revealed a 68 year old male admitted on 03/30/2016 1233 with a diagnosis of colon cancer metastasized to small intestine and was discharged on 04/25/2016 at 1740. Review of the Nursing Flowsheets from 03/30/2016 through 04/25/2016 revealed documentation of hygiene care on 03/30/2016 at 2230 patient refused hygiene care, 03/31/2016 at 1000 oral care and linens changed, 04/01/2016 at 0745 foley care and at 0000 foley care and peri care, patient refused all other hygiene care, 04/02/2016 at 0900 bathed, 04/03/2016 at 0800 peri care and at 1400 bed linen and bed pad changed, 04/04/2016 at 0950 teeth brushed, linen changed, gown changed, bathed and foley care and at 1500 bathed, linen changed, bed pad changed and gown changed, 04/05/2016 at 1500 patient refused hygiene, 04/06/2016 at 2119 bathed, hair washed, foley care, linen changed, bed pad changed and gown changed, 04/07/2016 at 0900 peri care, foley care, linen changed, bed pad changed and gown changed, 04/08/2016 at 0600 foley care, peri care, linen changed and bed pad changed, 04/09/2016 at 2000 patient refused hygiene care, 04/10/2016 at 2000 bed pad changed, 04/11/2016 at 0800 bathed and at 1530 bathed, 04/12/2016 at 0800 linen changed, bed pad changed and gown changed and at 2000 patient refused hygiene care, 04/13/2016 at 0630 linen changed and bathed and at 1000 teeth brushed, 04/14/2016 at 1400 bed pad changed and linen changed and at 2252 bed pad changed, linen changed and gown changed, patient refused bath, 04/15/2016 at 0800 linen changed and at 2117 peri care, 04/16/2016 at 0800 bed pad changed and at 1000 linen changed and bed pad changed and at 2200 linen changed, bed pad changed and gown changed, 04/17/2016 at 1400 bathed and at 2117 patient refused hygiene, 04/18/2016 at 0734 linen changed and bed pad changed and at 2200 bed pad changed and linen changed, 04/19/2016 at 0900 gown changed and at 2000 bed pad changed, 04/20/2016 at 1130 gown changed and at 2000 patient refused hygiene and at 2200 linen changed, 04/21/2016 at 0800 linen changed and bed pad changed and at 1230 bathed, peri care and gown changed, 04/22/2016 at 0600 bed pad changed and at 0940 teeth brushed, mouth moisturizer, bed pad changed and linen changed, 04/23/2016 at 0600 peri care, linen changed and bed pad changed, 04/24/2016 at 1100 linen changed and bed pad changed and at 1900 bathed, peri care, linen changed and gown changed and at 2000 hygiene offered but patient refused stating it was just done at 1900, and on 04/25/2016 at 1600 bed pad changed, patient discharged home at 1740. Further review of medical record revealed no available documentation of hygiene care/bath given on 03/31, 04/01, 04/03, 04/05, 04/07, 04/08, 04/09, 04/10, 04/12, 04/15, 04/16, 04/18, 04/19, 04/20, 04/22 and 04/23/2016 (16 of 27 admission days).

Interview with NCA #1 (nursing care assistant) on 04/27/2016 at 1350 revealed "I have worked in this job for 1 and 1/2 years. I worked with the named patient 4-5 times during his stay. The patient never complained to me about baths not being done. I usually bath my patients every other day, unless the patient request a bath, then I do. I am not sure what the policy states for bathing patients."

Interview with NM #1 (nurse manager) on 04/28/2016 at 1200 revealed nursing staff are expected to bathe patients every day unless the patient has contraindications and document bath/hygiene care in the nursing flow sheet. Interview revealed "we should bathe our patients daily. We should follow the hospital's basic care policy. I have identified issues with staff not completing documentation and tasks as assigned. I am in the beginning stages of arranging a NCA (nursing care assistant) academy to hold workshops for flowsheet documentation training, hand-off reports (shift to shift reporting), validation of competencies and policy review." Interview confirmed there was no available documentation of a bath given on 03/31, 04/01, 04/03, 04/05, 04/07, 04/08, 04/09, 04/10, 04/12, 04/15, 04/16, 04/18, 04/19, 04/20, 04/22 and 04/23/2016 (16 of 27 admission days). Interview confirmed nursing staff did not follow hospital policy for hygiene care of the hospitalized patient.

2. Closed medical record review revealed Pt # 5 was hospitalized from 01/11/2016 to 01/21/2016. Review revealed the patient had surgery on 01/11/2016 and 01/15/2016. Record review revealed Pt # 5 received baths on 01/13/2016, 01/16/2016 and 01/19/2016. Review revealed Pt # 5 refused a bath on 01/11/2016, and an attempt to bathe was made on 01/20/2016. No evidence of a daily bath was available for 01/12/2016, 01/14/2016, 01/17/2016, or 01/18/2016.

Interview with NM # 2, on 04/28/2016 at 1100, revealed there was no evidence that baths had been given or offered on the days mentioned above. Interview revealed this had been identified as a concern and a staff education session was planned. Interview revealed policy was not followed.

NC00116161, NC00113635