HospitalInspections.org

Based on observation, interview and record review, the facility failed to ensure that 2 of 10 patients (#3 and #5) were assessed and treated for complaints of pain. Findings include:

***Policy 3.21 "Pain Management," dated 7/1/10 states:
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A. "Patients will receive timely pain assessments, intervention and evaluation for effectiveness of pain management."
B. "Pain assessment starts at admission and continues throughout hospitalization and, if needed, planning for continuity of pain management at discharge."
C. "Patients will participate in developing plans for the management of their pain."
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B. "Patients are also evaluated for pain on a daily basis during regular vital sings checks and intervention initiated as needed. Patients are asked to describe the pain, rate the intensity of the pain on a numeric scale from 1-10, give location of pain..."

Patient #3:

1) On 8/21/11 at 0730 hrs. the Nurse Manager made a "Late Entry for 8/20/11 at approximately mid-day" noting that patient #3: "stated her hand hurt and she fell earlier in day."

2) On 9/12/11 at 1230 hrs. the CNO was asked whether there was any further assessment or follow-up to the report of injury received by the Nurse Manager (on 8/20/11) prior to 8/21/11. The CNO verified that there was no documentation of further assessment or follow-up until 8/21/11 and that the report of injury should have been documented on 8/20/11.

Patient #5:

1) On 9/12/11 at 1000 hrs. patient #5 complained of left knee pain to this surveyor and the Chief Nursing Officer (CNO) that was preventing her from attending a morning treatment group. The left knee appeared to be swollen. Patient #5 stated that she has "bad arthritis" and that the nurse on duty and a nurse on the previous shift (at 0500 hrs.) had refused to administer pain medication as ordered. Patient #5 stated that some nurses give Flexeril and Norco together, when she complains of extreme pain and others refuse and give only the less effective medication, the Flexeril.

2) On 9/12/11 at 1040 hrs, review of patient #5's "Initial Pain Assessment" revealed complaints of knee, ankle and back pain at a level of 8 out of 10 with a throbbing quality.

3) Patient #5 received medication for pain on a daily basis since admission on 9/711 but pain was not identified as a problem on patient #5's "Individualized Plan of Service (ISP)."

4) On 9/12/11 at approximately 1045 hrs. review of patient #5's "Medication Administration Record' (MAR) revealed that some nurses administered Flexeril and Norco at the same time and others did not. Both medications were ordered on a PRN (as needed) basis for pain with no directions for not giving them together and no administration directions according to pain level.

5) Documentation revealed that patient #5 was not given any Norco or Flexeril on the morning of 9/12/11 until 0900 hrs. when she received only Flexeril. There was no documentation of a pain assessment on 9/12/11 or reason for giving only Flexeril in response to patient #5's complaints of extreme pain.

6) On 9/12/11 at approximately 1045 hrs, patient #5's nurse, Nurse #1, was asked if she was aware of patient #5's complaints of extreme pain this morning. Nurse #1 stated that she was aware of the patient's complaints. Nurse #1 was asked if she had documented a pain assessment. Nurse #1 stated that she had not. Nurse #1 was asked if patient #5 had requested both Norco and Flexeril that morning and, if so, how she had responded. Nurse #1 stated that patient #5 had requested both medications but that it was her practice not to give the two medications together because both have possible side effects of sedation. Nurse #1 stated that she had not observed that patient #5 was overly-sedated this morning and that she had not reported patient #5's complaints of unrelieved pain to her physician.

7) On 9/12/11 at approximately 1100 hrs., the CNO confirmed that patient #5's clinical record revealed that pain assessments had not been on a daily basis since her admission on 9/7/11. The CNO also verified that there was no policy against giving two medications with side effects of possible sedation at the same time and that nurses are responsible for reporting unrelieved pain to the patient's physician. The CNO also verified that pain should had been listed as a problem in patient #5's ISP.

1) An 8/21/11 at 0730 hrs. the Nurse Manager made a " Late Entry for 8/20/11 at approximately mid-day " noting that patient #3 " stated her hand hurt and she fell earlier in day. "
2) On 9/12/11 at 1230 hrs. the CNO was asked whether there was any further assessment or follow-up (prior to 8/21/11) to the Nurse Manager ' s undocumented late entry, noting that he was informed by the patient of an injury sustained on 8/20/11. The CNO verified that there was no documentation of further assessment or follow-up until 8/21/11.