HospitalInspections.org

Based on review of Patient #1's medical record, the medication administration record, Hospital policy and interviews with Hospital staff, the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for Patient #1 in regards to pain medication administration and pain assessment/reassessment.

Findings include:

Background information - Patient #1 was 47 years old with a history of non-insulin dependent diabetes, hypertension, hyperlipidemia, asthma, obesity, back pain with previous lumbar discectomy surgery. Patient #1 was scheduled for elective hip surgery on 4/25/12.

1) Review of the Medication Administration Record [MAR] dated 4/25/12 indicated that Patient #1 received intravenous narcotics intraoperatively. In the Recovery Room, 20 milligrams [mg] of Morphine, 2 mg of Dilaudid and 2 mg of Midazolam were administered intravenously over a time span from 1:23 P.M to 2:37 P.M. Patient #1 was transferred to the inpatient unit where additional intravenous narcotics were administered. Review of the MAR dated 4/25/12 indicated that 2 mg of Dilaudid was administered intravenously at: 3:58 P.M., 5:09 P.M., 7:21 P.M., 10:02 P.M. and the last dose on 4/26/12 at 3:12 A.M. A total amount of 10 mg of Dilaudid was administered intravenously over a period of approximately eleven hours.

2) Review of the Audit Trail - Pain Documentation sheet dated 4/25/12 and 4/26/12 indicated that nursing staff did not consistently re-assess the Patient's level of pain every 30 minutes as required by hospital policy.

3) Review of the Hospital Pain Management Policy, page 3, section titled Giving Medications indicated that if the patient needs still more pain relief, the nurse may administer a strong opioid (such as Dilaudid) as prescribed. On page 4 of the policy, it indicates that the nurse must assess the patient's pain 30 minutes after parenteral (intravenous) administration. If the patient is still in pain, reassess the patient and alter the care plan as appropriate.

4) Review of the Pain Documentation sheet dated 4/25/12 at 10:56 P.M. indicated that Patient #1 complained of pain at a level of 5 out of 10 [1 is no pain and 10 is the worst pain possible] with behavior documented as resting comfortably. This was 54 minutes after the administration of the pain medication.

The next documented pain assessment occurred at 2:23 A.M. on 4/26/12. Patient #1 was recorded as complaining of pain at a level of 3 out of 10 with behavior as resting comfortably. Review of the MAR indicated that Patient #1 received 2 mg of Dilaudid intravenously at 3:12 A.M. with no documentation of assessment of change in pain reported.

At 4:04 A.M., fifty two minutes after the last dose of Dilaudid was administered, Nurse #'1's documentation indicated that Patient #1 was resting comfortably. The reassessment of pain was recorded at a level 3.

5) Registered Nurse (RN) #1 was interviewed on 6/15/12 at 9:10 A.M. RN #1 said Patient #1 had been sleeping because she/he received quite a lot of pain medications in the Post Anesthesia Recovery Room. Nurse #1 said she heard Patient #1 snoring loudly around 1:30 to 2:00 A.M. Nurse #1 said she returned around 3:00 A.M. and the Patient complained of pain and 2 mg of Dilaudid was administered intravenously. Nurse #1 said she returned around 4 A.M. and the Patient was sleeping and not snoring.

6)The Risk Manager was interviewed on 6/29/12 at 8:30 A.M. The Risk Manager said that during the Root Cause Analysis, RN #1 said she did not wake Patient #1 up around 4 A.M. to assess him/her. The Risk Manager said that RN #1 documented the Patient's pain level as 3 because she assumed that because the Patient was "fresh" post-operative, some pain was present. Nurse #1 did not wake the Patient to conduct an assessment because she assumed the Patient was asleep and did not want to wake him/her. Nurse #1 documented her assumption, not objective information based on a nursing assessment.

7) Review of RN #1's nursing progress note dated. 4/26/12 at 5 A.M. indicated that she found Patient #1 with no pulse or respirations. A code was called and ended at approximately 5:47 A.M. Patient #1 was pronounced dead.