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Based on interviews and review of documentation, it was determined that the Hospital had not yet completed an action plan related to the Serious Reportable Event regarding Patient (Pt) #1.

Findings include:

Review of the Hospital's Internal Investigation indicated that the 91 year old patient, Pt # 1, was admitted to the hospital on 5/23/12 after a fall at home. On 5/24/12, while hospitalized Pt #1 fell again. Pt #1 was evaluated and the medical examination was negative except for pain and limited mobility. The initial x-ray report of Pt #1's right hip was negative. Pt #1 was discharged on 5/30/12 despite Pt #1's continued complaints of severe pain with movement, and the physical therapist's concern regarding the degree of pain associated with movement. Pt #1 was readmitted on 5/31/12 and Pt #1 had a radiological imaging study on 6/1/12 that identified a fractured right hip. On 6/5/12, Pt #1 had a surgical repair of the fractured hip, 12 days after the fall.

1)The Risk Manager was interviewed on 7/11/12 at 8:15 A.M., the Director of Physical Therapy on 7/11/12 at 1:30 P.M. and the Chief of Medicine on 7/12/12 at 7:30 A.M. All staff said that the SRE was reviewed at the Falls Committee and at the Department of Medicine Grand Rounds (6/28/12). However, the Hospital had not implemented any corrective actions regarding the delay in diagnosis of Patient #1's hip fracture and surgical repair.

Based on medical record review and Hospital policies and procedures related to pain management, the nursing staff failed to follow Hospital policy and procedures related to pain assessment and management for 1 (Pt #1) of 10 patient records reviewed.


Findings include:

1) Review of the Hospital's Pain Management Policy indicated that the goal was to keep a patient's pain level below 4 whenever possible. The patient may agree to a higher rating as being his/her standard. A family member and/or significant other will be involved with a patients pain management plan. The policy indicated that a patient will be reassessed within 60 minutes after a pain intervention. The policy indicated that when a patient does not meet the pain standard of 4 or below, a physician needs to be notified for re-evaluation of the pain management plan. If the patient does still not meet the pain management standard, the physician needs to call an anesthesia physician on call for a pain consult.

2) Review of the Emergency Department (ED) nursing note dated 5/23/12 indicated that Pt #1 complained of left sided rib pain and rated her/his pain level at 10 at 4:14 P.M. Review of Pt #1's electronic medication administration summary report [medication administration record (MAR)] indicated that at 4:14 P.M., Pt #1 received Tylenol for pain. Review of the MAR at 4:25 P.M. indicated that a Lidoderm patch was applied to Pt #1 for complaints of pain. The nurse failed to document a reassessment of Pt #1's pain after Pt #1 received Tylenol and a Lidoderm patch as required by Hospital policy.

3) Review of the admission nursing assessment dated 5/23/12 at 8: 00 P.M. indicated that Pt #1 was admitted to a patient care unit. The assessment indicated that Pt #1 denied pain. Review of Pt #1's MAR dated 5/23/12 at 10:20 P.M. indicated that Pt #1 rated her/his pain at a level 5 and received Tylenol. The nurse failed to document a reassessment of Pt #1's pain after Pt #1 received Tylenol.

4) Review of the nursing assessment dated 5/24/12 at 1:24 A.M. indicated that Pt #1 reported no pain. However, the assessment indicated that Pt #1 complained of pain on his/her left side with movement. The nurse failed to document a pain level number associated with movement.

5) Review of the MAR dated 5/24/12 at 4:44 A.M. indicated that Pt #1 rated his/her pain at 10 and was administered Tylenol for pain relief. The nurse failed to document a reassessment after Pt #1 received Tylenol.

6) Review of the MAR dated 5/24/12 at 10:57 A.M. indicated that Pt #1 reported her/his pain at 10 and was administered Tylenol for pain relief. The nurse failed to document a reassessment after Pt #1 received Tylenol.

7) Review of the nursing note dated 5/24/12 indicated that at 1:15 P.M. Pt #1 was found on the floor. Pt #1 complained of pain in his/her right buttock. The nurse failed to document the severity of the pain.

8) Review of the nursing shift assessment dated 5/24/12 at 1:39 P.M. indicated that Pt #1 reported no pain, which was inconsistent with documentation on Pt #1's MAR and the nursing progress note.

9) Review of the MAR dated 5/25/12 at 9:22 A.M. indicated that Pt. #1 reported his/her pain at 10 and received Oxycodone (narcotic) for pain relief. Review of the nursing documentation dated 5/25/12 did not include a pain reassessment within 60 minutes of the Oxycodone administration as required by the Pain Management Policy

10) Review the Nursing Documenentation and MAR's dated 5/26-5/30/2012 indicated that Pt #1 continued to rate his/her pain level from 3 to 10 with movement and continued to receive Tylenol for pain management. Review of the nursing documentation did not include pain reassessments within 60 minutes or follow up of interventions with pain greater than 4 as required by the Pain Management Policy.

Based on review of 3 (Pt #1, Pt #2, #3) of 10 nursing care plans the facility failed to ensure that nursing cares plan were developed according to patient issues/problems identified.


Findings include:

1) Review of the admission nursing assessment dated 5/23/12 indicated that Pt #1 rated her/his pain at 5. The pain was described as constant and stabbing. There were no factors which alleviated Pt #1's pain. The assessment indicated that the management of Pt #1's pain was an important part of Pt #1's treatment.

Review of Pt #1's plan of care dated 5/23/12 indicated that Pt #1's problem/issue with pain were not addressed in the plan of care.


2) Review of the medical progress note dated 7/9/12 indicated that Pt #2 had bloody diarrhea.

Review of Pt #2's plan of care dated 7/19/12 indicated that Pt #2's problem/issue with gastrointestinal function was not addressed in Pt #1's plan of care.


3) Review of the imaging study report dated 7/8/12 indicated that Pt #3 had kidney dysfunction and uretal stents (a thin tube inside the structure that carries urine from the kidney that id used to prevent or treat obstruction of urine flow) were in place.
Review of Pt #3's plan of care dated 7/3/12 indicated that Pt #3's problem/issue with urinary function was not addressed in Pt #3's plan of care.

Based on review of 1 (Pt #3) of 10 patient records reviewed, the facility failed to ensure that the medication Lasix (a medication used to reduce the swelling and fluid retention caused by various medical problems) administered by a nurse, was administered according to hospital policy and procedure.

Findings include:

1) Review of the Hospital's Medication Administration Policy indicated that the medication administration procedure included the 7 rights for safe medication administration. One of the seven rights indicated that the right documentation will occur. The policy and procedure indicated that a nurse will use a bedside bar code scanning process for all medications administered, except in situations of cardiopulmonary arrest, patient emergencies, procedural sedation, electronic system down time and an absent or unreadable barcode.

Review of the physician orders in Pt #3's medical record dated 7/8/2012 at 1:00 P.M. indicated that Lasix 40 mg IV was administered for a nuclear medicine scan. This Lasix administration was not documented on Pt #3's MAR in accordance with the Hospitals Medication Administration Policy.

Based on review of 7 (Pt #1, Pt #2, Pt #3, Pt #5, Pt #6, Pt #7 and Pt #10) of 10 patient records, the facility failed to ensure that all progress notes were timed, all signatures were legible and dates were correct.

Findings include:

1) Review of the progress note in Pt #1's medical record dated 6/4/2012 at 12:35 P.M. indicated that the signature was illegible.

2) Review of the consultation in Pt #2's medical record dated 7/9/2012 indicated the time of the consult was not documented.

Review of the progress notes in Pt #2's medical record dated 7/10/2012 and 7/11/2012 indicated that the notes were not timed and the signature was illegible.

Review of page #3 in the 3 page post procedure record in Pt #2's medical record dated 7/11/12 indicated that the nurse's signature was illegible.

3) Review of the medical progress notes in Pt #3's medical record indicated that a progress note was not dated and timed.

4) Review of the medical progress note in Pt #5's medical record dated 7/16/2012 at 12:00 P.M. indicated that the signature was illegible. Review of the progress note dated 7/17/2012 indicated that the entry was not timed. Review of the Rapid Response Team Record dated 7/15/2012 indicated that the team was notified at 2:20. However, the record did not indicate whether it was A.M. or P.M. The signatures on the Rapid Response Team Record were illegible.

5) Review of the entry in Pt #6's medical record dated 7/3/12 indicated that a Power PICC catheter (catheter used for short or long-term peripheral access to the central venous system for intravenous therapy) guide was entered into Pt #6's record without identification of who posted the guide.
6) Review of the medical progress notes dated 7/11, 7/12, 7/13, 7/14 and 7/16/12 in Pt #7's record indicated that the entries were not consistently timed and the signatures were not legible.

7) Review of the consent for hospital treatment in Pt #10's medical record indicated that the consent was dated incorrectly - 6/16/12 for the July 2012 hospitalization.