HospitalInspections.org

Based on policy and procedure review, medical record reviews, and staff interviews, the nursing staff failed to assess and/or reassess pain according to hospital policy for 4 of 11 patients reviewed (Pts # 14, 15, 19, 21).

The Findings include:

Hospital policy review on 12/03/2014 of the "Pain Management Policy", effective 06/18/2013, revealed "...Assumptions....The management of pain requires assessment, reassessment and follow up utilizing objective measurement and subjective assessment techniques....Purpose: To outline pain assessment and management strategies....Reassessment....2) At a minimum of q (every) 4 h (hours) if patient not satisfied. 3) Within one 1 hour following any intervention (i.e.scheduled or prn analgesia medication, change in treatment plan, or non-pharmacological action). ..." Review of "Appendix B: Pain Management Assessment/ Reassessment" revealed for a patient with "No pain intervention" the initial assessment is "Upon admission to outpatient clinic or inpatient unit". Further review revealed for PCA (Patient controlled analgesia), the initial assessment is "Prior to initiation and upon admission to unit" and ongoing assessments are "Every two hours for the first 24 hours and then every 4 hours unless dosage increased, then every 2 (hours) for 24 hours". Further review revealed that for "All other Medications" initial assessments are done "prior to administration of medication" with ongoing assessments done "every 4 hours and with a change in caregiver". Continued review revealed reassessments after intervention, including boluses, "Within 1 hour" for each of the following: PCA, Epidural/Regional, All other Medications, and Non Pharmacologic Measures.
1. Closed medical record review of patient #14 revealed the patient presented to the Emergency Department (ED) on 07/19/2014 at 1951 by ambulance with a chief complaint of weakness, questionable signs of stroke and leg pain. Review of nursing documentation at 1953 revealed the patient complaints were "rotating" to leg pain, eye pain and leg numbness. Review of documentation at 1958 revealed the patient complained of dull pain at a level of 6 on a 10 point scale (10 being the worst pain). Record review revealed documentation by the physician at 2111 the patient initially had pain at a level of 10 out of 10 that was sharp and constant but had decreased to a rate of 6. Record review revealed no documentation of reassessment of the patient's complaint of pain. Record review did not reveal any documentation of interventions provided for the patient's complaint of pain. Record review revealed the patient was discharged on 07/20/2014 at 0230.
Interview with administrative ED staff on 12/03/2014 at 1155 revealed there was no documentation of reassessment of the patient's complaint of pain and any interventions provided to the patient's. The interview revealed the staff should have provided an intervention for the patient's complaint of pain and reassessment of the pain.

2. Closed medical record review of patient #15 revealed the patient presented to the Emergency Department (ED) on 06/10/2014 at 1519 by ambulance with a chief complaint of pain, large abscess on the left buttock and cellulitis of the left thigh. Review of nursing documentation revealed "26 yr old female coming to the ED from Clinic with lg (large) buttock abscess. In a lot of pain. Difficult to examine. New rt thigh cellulitis. " Review of documentation at 1522 during triage revealed the patient had been sent from the physician's office by EMS for a surgical evaluation of an abscess. Record review revealed documentation at triage temperature 99.1, pulse 79, respirations 20 and blood pressure 122/71. Record review did not reveal any documentation of an assessment of the patient complaint of pain. Record review revealed at 1602 the patient asked about the wait times. Record review revealed at 1706 documentation by the physician of a medical evaluation at triage " I have evaluated the patient and initiated the medical screening exam and diagnostic evaluation. Currently, there is no bed available. The patient will return to the waiting room, but will be placed in a bed as soon as possible as one is available to complete evaluation and treatment. I have discussed the plan of care with the patient. 26 y.o. AAF w/hx (with history) presenting w/5d (with 5 days) of an intergluteal fold abscess w/some purulent drainage, intermittent fever to 100, nausea w/o (without) vomiting, unable to defecate due to severe paint. On exam, pt is in sign discomfort, unable to complete exam due to severe pain in triage room. Concern for perirectal abscess, will initiate labs, symptomatic tx (treatment) and CT from triage. Awaiting pod bed". Medical record review revealed the patient was administered Dilaudid (narcotic pain medication) 2 mg and Zofran (antiemetic) 4 mg IV at 1735. Record reviewed revealed at 1735 with the administration of medication, the patient rated her pain at an 8 on a 10 point scale with 10 being the most severe. Record review did not reveal any documentation of reassessment of pain within 1 hour after medication intervention. Record review revealed documentation the patient complained of pain at 2050 of 10 out of 10, the most severe pain. Record review did not reveal any documentation of an intervention or reassessment of pain. Record review revealed the patient informed the staff she was leaving before treatment completed at 2320.
Interview with administrative ED staff on 12/03/2014 at 1155 revealed there was no documentation of assessment of the patient's complaint of pain at triage. The interview revealed there was no documentation of reassessment of pain after medication was administered. The interview revealed there was no documentation of intervention after the patient complained of pain at 2050 . The interview revealed the staff should have provided an intervention for the patient's complaint of pain and reassessment of the pain.





33790

3. Closed medical record review of Patient # 19 revealed the patient underwent an aortic valve replacement on 08/18/2014. Review of Medication Orders revealed an order on 08/19/2014 at 1052 for "Hydromorphone (Dilaudid) PCA (Patient controlled analgesia) 1 mg/ml (milligram per milliliter)". Further review revealed an order, dated 08/19/2014 at 1026 for "Nursing: Pain Assessment every 2 hours for 24 hours: then q (every) 4 hours along with respiratory rate and sedation level, while on PCA." Review of MAR (Medication Administration Record) revealed PCA "Start: 08/19/14 1145 End: 08/21/14 1038". Review of pain assessments revealed the patient was assessed at least every two hours from 1000 to 2100. Review revealed the next pain assessment at 0000 on 08/20/2014 (3 hours later). Further review of pain assessments within the first 24 hours of the PCA revealed documentation of assessments on 08/20/2014 at 0400 (4 hours later), 0805 (4 hours), and 1155 (3 hours, 50 minutes). Review of MAR revealed the PCA was stopped 08/21/2014 at 1038. Review of Medication Orders revealed an order on 08/21/2014 at 1038 for Oxycodone (Roxicodone) immediate release tab 10-15 milligrams (mg)every 4 hours as needed for pain. Review revealed the order to give 10 mg for pain levels of 3-7 and 15 mg for pain levels of 8-10. Review revealed an assessment 08/21/2014 at 2034 with a score of 9. Review of the MAR revealed the patient was medicated with Roxicodone 15 mg at 2040. Further review of pain assessments revealed a pain assessment at 08/22/2014 at 0004 (3 hours 24 minutes later), with a pain score of 9. Review of MAR revealed the patient was medicated with Oxycontin CR 10 mg orally 08/22/2014 at 0009. Further review revealed a pain assessment at 0429 (4 hours later).
Interview with Nurse Manager (NM) # 1 on 12/04/2014 at 1100 following record review acknowledged no evidence of pain reassessment within one hour of medication administration for the medications given 08/21/2014 at 2040 and 08/22/2014 at 0009. Further interview confirmed that pain assessments were not done every two hours for the first 24 hours of the PCA. Interview revealed "they did at first, it was after change of shift" that the time of assessments changed to 4 hours. Interview confirmed staff did not follow the policy for pain assessment and reassessment.





27381

4. Closed medical record review for Patient #21 revealed a direct hospital admission on 07/11/2013 for postoperative pain and infection. Review of the physician's admission History and Physical revealed "on 7/3/2013 underwent laproscopic left superficial groin dissection for malignant melanoma. after being discharged on 7/4 . . . initially did well, until on 7/9 . . . began developing pain in the L [left] inguinal region. Pain was worse on straining and when this pain . . . failed to resolve after 24 hours . . . contacted Dr. . . " Review of nursing assessment notes and medication administration records (MAR) revealed pain assessment on 07/11/2013 at 1631 was 7 on a scale of 10 with 10 being the most severe pain. Continued review of the MAR and nursing notes revealed pain reassessment at 1810 was 7/10. Review of nursing notes revealed the physician was notified and new pain medication orders were received. Continued review revealed an intravenous (IV) patient controlled analgesia (PCA) pump was initiated with Dilaudid 1mg/ml at 1806 with a 0.5 mg bolus given at 1810. Continued review of nursing notes and MAR revealed the next pain reassessment was conducted 07/12/2013 at 0108 (5 hours and 58 minutes later). Pain reassessment on 07/12/2013 at 0842 (7 hours and 34 minutes) was 8/10 . Continued review of the MAR and nursing notes revealed at 1045 pain reassessment was 8/10. Continued review revealed the next pain reassessment was at 1420 (3 hours and 35 minutes) and the pain reassessment was 8/10. Continued review revealed at 1500 Dilaudid 1 mg IV bolus given with the next pain reassessment at 2013 (5 hours and 13 minutes) when pain was 5/10 and a Dilaudid 1 mg IV bolus was administered. Continued review revealed the pain reassessment was conducted at 2329 (3 hours and 16 minutes later) and the patient's pain was 6/10 . The next pain reassessment was on 07/13/2013 at 0436 (5 hours and 7 minutes) and pain was 7/10 with a Dilaudid 1mg IV bolus given. Continued review revealed the next pain reassessment was 0824 (3 hours and 12 minutes later) and was 6/10. Record review revealed nursing staff failed to provide pain management reassessment per hospital policy for a patient receiving PCA pain management.

Interview with RN #1 on 12/02/2014 at 1150 revealed nursing staff are expected to conduct a pain reassessment every 2 hours for the first 24 hours when a patient's pain is being managed by a PCA. The interview also revealed nursing staff are to conduct a pain reassessment every 2 hours for 24 hours if the PCA dosage changes or a bolus of pain medication is administered. Interview revealed the nursing staff failed to follow the hospital's policy for assessing and reassessing Patient #21's pain.