HospitalInspections.org

Based on document review, medical record (MR) review and interview, in 1 of 1 MR (Patient #1) of a patient who required a safety watch, nursing staff did not ensure the daily 1:1 Safety Watch Observation form was completed on each shift and placed in the MR per the facility's policy and procedure (P&P). This could cause staff to be unaware of the patient's condition and/or behavior and lead to untoward outcomes.

Findings include:

-- Review of the facility's P&P titled "Safety Watch, Security Watch (Including Suicidal, Violence, Detoxification Concerns), last revised 5/2020, indicated a patient is placed on watch when the patient's behavior or diagnosis creates an unsafe situation for the patient and/or others. The registered nurse (RN) assigned to the patient will orient the 1:1 sitter based on the patient's status and plan of care for each shift. The "Daily 1:1 Behavioral Form" is utilized to discuss care needs. Documentation on the form should be done on each shift that an observer is assigned to the patient. Documentation should include the reason for watch, behaviors observed, needs and activity of daily living needs. The completed form is placed in the patient's MR in the flow sheet section.

-- Review of Patient # 1's MR revealed, after her fall on 12/10/19, she was assigned a 1:1 sitter for safety until her discharge on 1/2/2020. The MR lacked documentation on the Daily 1:1 Behavior form on all but one shift during that time frame (24 days).

-- During interview of Staff A (Clinical Nurse Specialist) on 7/23/202 at 11::23 am, he/she acknowledged the above finding and indicated the expectation is that the form should be completed on each shift per the P&P.

Based on document review, medical record (MR) review and interview, in 3 of 3 MRs reviewed, (Patient # 2, #3 and #4), staff did not document timely pain reassessments after administration of pain medication. This lack of reassessment documentation does not indicate if the pain management intervention was effective.

Findings include:

-- Review of the hospital's policy and procedure (P&P) titled "Pain Management (Non-Epidural)," effective date 7/9/19, indicated pain will be reassessed after each pain management intervention, based upon the pharmocological properties of the analgesic(s) administered. For PRN (as needed) interventions, effectiveness should be assessed within one hour and include pain score when patient is awake. The pain scale is 0 (zero) for no pain, 1-3 for mild pain, 4-7 for moderate pain and 8-10 for severe pain.

-- Per review of Patient #2's MR, nursing administered intravenous opioid pain medication on 7/17/2020 at 12:23 pm due to a pain level of 10/10 for incisional pain. A pain reassessment was documented at 3:08 pm (2 hours and 45 minutes) after it was administered with a pain level of 10/10.

-- Per review of Patient #3's MR, nursing administered oral opioid pain medication on 7/19/2020 at 6:12 am due to a pain level of 6/10 for incisional pain. A pain reassessment was documented at 8:54 am (2 hours and 42 minutes) after it was administered with a pain level of 2/10.

-- Per review of Patient #4's MR, nursing administered oral opioid pain medication on 7/19/2020 at 1:30 pm due to a pain level of 5/10 for incisional pain. A pain reassessment was documented at 5:02 pm (3 hours and 32 minutes) after it was administered with a pain level of 7/10.

-- During interview of Staff B, Registered Nurse (RN) on 7/20/2020 at 10:35 am, patients are assessed for pain with their vital signs check. Pain level is documented with a numeric number. He/she also looks at a patient's body language and facial expression as a pain indicator. For oral medications administered for pain, the patient is reassessed in 1 hour. For intravenous (IV) medications administered for pain, the patient is reassessed in 30 minutes. Reassessments are documented in the MR.

-- During interview of Staff C, RN on 7/20/2020 at 1:10 pm, patient pain levels and reassessments are documented in the medication administration record (MAR). Effectiveness of oral pain medications are done within 1 hour of administration and IV pain medications are done within 30 minutes of administration.

-- During interview of Staff D, RN on 7/20/2020 at 3:10 pm, patient's pain reassessments are done 15 minutes after IV pain medication administration and 1 hour after oral pain medication administration and documented.

-- During interview with Staff E, Director of Women's and Infant Health on 7/20/2020 at 11:45 am, the above findings were acknowledged.