HospitalInspections.org

Based on policy review, staff interview, and medical record review the hospital's nursing staff failed to supervise and evaluate patient care by failing to assess pain and/or failing to complete a comprehensive initial nursing assessment per policy for 6 of 11 sampled patients (#11, #8, #4, #3, #10, and #2).

The findings include:

Review of current hospital policy entitled "Nursing Assessment/Initial Plan of Care" dated 09/2009 revealed, "...An RN (registered nurse) will complete the comprehensive nursing assessment within sixteen hours of admission to the unit....If the RN is unable to complete the assessment at the time of admission, a note will be entered into the progress notes explaining the reasons....The nursing assessment includes the identification of the following:...Pain assessment....The patient is reassessed daily, as evidenced by the daily RN note, in order to properly delegate nursing care...."

Review of current hospital policy entitle "Pain Assessment and Management" dated 09/2009 revealed, "...2. Upon admission to a unit, an initial assessment of chronic or acute pain is initiated and documented by a registered nurse and is part of the Nursing Assessment. 3. If a patient reports chronic or acute pain, the nurse shall initiate a Comprehensive Pain Assessment which addresses intensity of pain, location, quality, accompanying symptoms, duration, context, timing and modifying factors....5. Once pain is documented, it is reassessed and documented each time vital signs are taken or more frequently as needed. Assessment and reassessment within one hour needs to be documented on the PRN (as needed medications) follow-up form...."

Interview on 05/03/2011 at 1445 with the Assistant Director of Nursing (ADON) revealed the RN must assess each patient for pain during the initial nursing assessment. Interview revealed if the patient reports acute or chronic pain during the initial nursing assessment, the nurse must complete a Comprehensive Pain Assessment, which is part of the initial nursing assessment form. Further interview revealed Mental Health Technician (MHT) staff take all patients' vital signs at least once per day, at which time the MHT staff asks each patient if they have pain. Interview revealed if the patient reports no pain to the MHT the nurse does not need to assess the patient for pain. Interview revealed if the patient reports pain to the MHT, the MHT asks the patient to rate the intensity of pain on a scale of 1 to 10 (with 10 being the most severe pain). Interview revealed the MHT documents the patient's reported pain level on the vital sign form and reports the patient's complaint of pain to the RN. Interview revealed the RN must then assess the patient for pain and call the physician if necessary or administer pain medications if needed. Interview revealed the nurse must document the pain assessment in the nursing notes. Interview revealed when a patient has reported pain, a RN should reassess the patient's pain at least once per shift, when medications are given for pain, and within one hour following the administration of pain medications.

1. Open medical record review for Patient #11 revealed a 13 year-old male that was admitted on 04/28/2011 with psychosis and rule out bipolar disorder. Review of the initial Comprehensive Nursing Assessment completed on 04/28/2011 at 1940 revealed the patient denied pain at the time of admission. Review of the Vital Signs form revealed MHT documentation the patient complained of pain as follows: on 04/30/2011 (no time) - pain level of 8 out of 10 reported (no location of pain); on 05/02/2011 (no time) - pain level of 7 out of 10 reported (no location of pain); and on 05/03/2011 at 0830 - pain level of 7 out of 10 reported (no location of pain). Record review revealed the first documentation that a nurse assessed the patient's pain was on 05/03/2011 at 1800 (3 days after the patient first reported pain to MHT staff), when the nurse gave the patient Motrin (pain reliever) for complaints of a headache. Record review revealed no documentation that a nurse assessed the patient's pain from the time the patient first reported pain to the MHT on 04/30/2011 until 05/03/2011 at 1800 (3 days).

Interview on 05/04/2011 at 1415 with the ADON revealed a registered nurse should have assessed the patient's pain after the patient report pain to the MHT. Interview confirmed there was no available documentation that a nurse assessed the patient's pain from the time the patient first reported pain to the MHT on 04/30/2011 until 05/03/2011 at 1800 (3 days).

2. Closed medical record review for Patient #8 revealed a 15 year-old female that was admitted on 03/09/2011 with bipolar disorder and post traumatic stress disorder. Review of the initial Comprehensive Nursing Assessment completed on 03/09/2011 at 1352 revealed the patient denied pain at the time of admission. Review of a physician's order dated 03/11/2011 at 0930 revealed, "Ibuprofen (pain reliever) 400 mg po q 6 (hours) PRN (milligrams by mouth every 6 hours as needed) - Back, Neck and R(ight) ankle pain." Record review revealed the nurse gave the patient Ibuprofen 400 mg on 03/11/2011 at 1100 for complaints of back pain. Record review revealed the next documentation that a nurse assessed the patient's pain was on 03/15/2011 at 1100 (4 days later), when the nurse gave the patient Ibuprofen 400 mg for complaints back pain that the patient rated as 10 out of 10 in severity. Record review revealed no documentation that a nurse assessed the patient's pain on 03/12/2011, 03/13/2011, or 03/14/2011. Record review revealed the patient was discharged home with her parents on 03/21/2011.

Further closed medical record review for Patient #8 revealed the patient was re-admitted on 03/24/2011 at 0845 with complaints of suicidal and homicidal ideations. Record review revealed a copy of the initial Comprehensive Nursing Assessment dated 03/09/2011 at 1352 (from the previous admission) with the following note added to the top of the page by the admission nurse and dated 03/24/2011 at 1600: "3/24/11 - Pt (patient) readmitted within 72 hrs (hours) of D/C (discharge). Denies change in status. LMP (last menstrual period) updated." Record review revealed no documentation of an initial Comprehensive Nursing Assessment completed within 16 hours of the patient's admission on 03/24/2011 at 0845. Review of the Vital Signs form revealed MHT documentation the patient complained of pain, with a reported level of 9 out of 10 reported (no location of pain), on 03/28/3011 (no time). Record review revealed the first documentation that a nurse assessed the patient's pain was on 03/31/2011 at 1415, when the nurse gave the patient Motrin for complaints of back pain. Record review revealed no documentation that a nurse assessed the patient's pain from the time the patient first reported pain to the MHT on 03/28/2011 until 03/31/2011 at 1415 (3 days). Further review of the Vital Signs form revealed MHT documentation the patient complained of pain on 04/02/2011 at 0830 (level 3 out of 10 - no location). Record review revealed the nurse gave the patient Motrin on 04/02/2011 at 2109. Record review revealed no documentation of a pain assessment before or after the Motrin was administered. Further review of the Vital Signs form revealed MHT documentation the patient complained of pain on 04/03/2011 at 0900 (level 7 out of 10 - no location). Record review revealed the next documentation that a nurse assessed the patient's pain was on 04/04/2011 at 1140 (1 day later), when the nurse gave the patient Motrin for complaints of "stomach" pain. Record review revealed the nurse reassessed the patient's stomach pain on 04/04/2011 at 1400 (2 hours and 40 minutes after Motrin was given). Record review revealed the patient was discharged home with her parents on 04/11/2011.

Interview on 05/04/2011 at 1415 with the ADON revealed a registered nurse should have completed a new Comprehensive Nursing Assessment within 16 hours when the patient was admitted on 03/24/2011, rather than update the Comprehensive Nursing Assessment from the previous admission. Further interview confirmed there was no available documentation that the nurse reassessed the patient's pain within one hour after the administration of Motrin for pain on 03/11/2011 at 1100, 04/02/2011 at 2109, and on 04/04/2011 at 1140. Interview confirmed there was no available documentation that a nurse assessed the patient's pain on 03/12/2011, 03/13/2011, or 03/14/2011. Interview confirmed there was no available documentation that a nurse assessed the patient's pain from the time the patient first reported pain to the MHT on 03/28/2011 until 03/31/2011 at 1415 (3 days). Further interview confirmed there was no available documentation that a nurse assessed the patient's pain from the time the patient reported pain to the MHT on 04/03/2011 at 0900 until 04/04/2011 at 1140 (1 day).

3. Closed medical record review for Patient #4 revealed a 12 year-old female that was admitted on 03/30/2011 with depression and post traumatic stress disorder. Review of the Vital Signs form revealed MHT documentation the patient complained of throat pain, which the patient rated to be 3 out of 10 in severity, on 04/02/2011 at 1000. Record review revealed the first documentation that a nurse assessed the patient's pain was on 04/03/2011 at 2030 (1 day and 10 1/2 hours later), when the nurse gave the patient Tylenol (pain reliever) for complaints of a sore throat. Record review revealed no documentation that a nurse assessed the patient's pain from the time the patient first reported pain to the MHT on 04/02/2011 at 1000 until 04/03/2011 at 2030 (1 day and 10 1/2 hours later). Record review revealed the patient was discharged on 04/07/2011.

Interview on 05/04/2011 at 1415 with the ADON revealed a registered nurse should have assessed the patient's pain after the patient report pain to the MHT. Interview confirmed there was no available documentation that a nurse assessed the patient's pain from the time the patient first reported pain to the MHT on 04/02/2011 at 1000 until 04/03/2011 at 2030 (1 day and 10 1/2 hours later).

4. Closed medical record review for Patient #3 revealed a 10 year-old female that was admitted on 04/20/2011 with depression, suicidal ideations, and oppositional defiant disorder. Record review revealed the nurse gave the patient Motrin (pain reliever) on 04/28/2011 at 1215 for complaints of face pain. Record review revealed the patient was discharged on 04/28/2011 at 1630. Record review revealed no documentation the nurse reassessed the patient's pain prior to discharge (4 hours and 15 minutes after the administration of Motrin for face pain).

Interview on 05/04/2011 at 1415 with the ADON confirmed there was no available documentation that the nurse reassessed the patient's pain prior to discharge (4 hours and 15 minutes after the administration of Motrin for face pain).




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5. Closed medical record review for Patient #10 revealed a 17-year old female admitted on 04/16/2011 with a diagnosis of cyclothymia (Mild Mood Disorder), post-traumatic stress disorder (PTSD), and suicidal ideation. Record review revealed an initial comprehensive nursing assessment, dated 04/16/2011, documented "No pain on admission: Yes ... Location: Back, Other Locations - list: right lower back, Intensity: 7-8 (Hurts Whole Lot), Type: Ache..." Review of physician's admission orders revealed the patient had no medication orders. Record review revealed the patient's pain rating was recorded by the MHT on the"Vital Signs" form as a "9 (out of 10)" on 04/18/2011 at 0900. Record review revealed a physician's telephone order, dated 04/18/2011 at 1505, to "Consult w (with)/ Dr (Name) Re(garding): stomach pain." Review of a "Consultation Form" dated 04/19/2011 at 1310 revealed, "Consultation Findings: S (Subjective): Sharp intermittent RUQ (Right Upper Quadrant) and Right flank discomfort, intermittent, onset (symbol for about) 4-16... A (Analysis): (?) (questionable) muscle strain, P (Plan): Tylenol, Urine Analysis." Record review revealed the patient's pain rating was recorded by the MHT on the"Vital Signs" form as a "7 (out of 10)" on 04/19/2011 at 0900. Record review revealed no physician orders for pain medication. Record review revealed a physician's order dated 04/26/2011 at 0925 to "offer gingerale 8 oz. (ounces) q (every) AM (morning) when abdominal discomfort." Record review of the MAR (Medication Administration Record) revealed the patient received Gingerale every morning from 04/27/2011 through 04/29/2011 (day of discharge). Record review revealed no documentation of a nursing assessment of pain (location, duration, intensity) on either 04/18/2011 or 04/19/2011 (dates patient complained of pain to MHT staff).

Interview on 05/04/2011 at 1400 with the Assistant Director of Nursing (ADON) revealed a registered nurse should have assessed the patient's pain after the patient report pain to the MHT. Interview confirmed there was no available documentation that a nurse assessed the patient's pain on 04/18/2011 or 04/19/2011.

6. Closed medical record review for Patient #2 revealed a 17-year old female admitted on 04/18/2011 with a diagnosis of cyclothmia (Mild Mood Disorder), post-traumatic stress disorder (PTSD), and suicidal ideation. Record review revealed the initial nursing assessment dated 04/18/2011 documented the patient had an "injury" to the "right hand" and no pain present on admission. Review of a "Master Treatment Plan" dated 04/18/2011 at 2230 revealed, "Problem II: Medical/Physical: right hand injury." Medical record review revealed a physician's order, dated 04/21/2011 at 0800, to "1. X-ray right hand...R/O (rule out) fracture-painful hand after hitting wall..." Record review of physician's progress note dated 04/21/2011 at 0825 revealed "right hand middle finger swollen." Record review revealed the patient's pain rating was recorded by MHT staff on the"Vital Signs" form as a "10" on 04/22/2011. Record review revealed no nursing assessment of pain (location, duration, intensity) on 04/21/2011 (date physician noted right hand injury and ordered x-ray) or on 04/22/2011 (date patient's pain recorded by MHT staff as a 10 on "Vital Signs" form).

Interview on 05/04/2011 at 1400 with the Assistant Director of Nursing (ADON) revealed a registered nurse should have assessed the patient's pain after the patient report pain to the MHT. Interview confirmed there was no available documentation that a nurse assessed the patient's pain on 04/21/2011 or 04/22/2011.

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