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Based on record review and interview the facility failed to ensure that the nursing care plan for pain reassessments are conducted are planned based on the response to treatment of one (1) out of 13 sampled patients (SP). (SP#24)

The Findings:

Interview on 5/19/15 at 11:40 am SP#24 stated that he had a history of diabetes and wounds. The patient also stated, "I was in pain yesterday." He mentioned that a new IV was placed by the next shift nurse at 9 pm that night. He further stated that he had concerns about receiving his pain medication yesterday and also had concerns with his day shift nurse and that he had informed the charge nurse regarding this matter.

Record review of the physician admission assessment notes dated 5/7/15 showed that SP #24 was admitted with the assessment impression of lower extremity cellulitis, chronic pain syndrome.

Review of the physician orders for pain medications of SP#24 showed Fentanyl patch 75 mcg / hr topical extended release every 72 hrs. Tramadol 50 mg orally PRN (as needed) every 4 hrs. Percocet 5 / 325 mg orally every 4 hrs PRN. Dilaudid 1 mg IV push Q 4 hrs PRN.

Record review SP#24 Medication Administration Record (MAR) flow sheet for May 2015 revealed Fentanyl patch 75 mcg / hr was administered topically Q 72 hrs on 5/16/15 at 2:47 pm. This patch was re-administered on 5/19/15 at 3 pm. Dilaudid 1mg IV (intravenous) push PRN was administered on 5/18/15 at 3:08 am, 8:55 am, 12:48 pm and 9 pm.

Record review of SP#24 MAR dated 5/18/15 revealed there was no oral pain medication administration between 1 pm to 8 pm.

Record review of SP #24 pain assessment dated 05/18/15 showed that at 3:08 am the pain score was 7 at which time the patient received dilaudid 1 mg IV. The patient was not reassessed 30 minutes later according to the pain assessment documentation.

On 5/18/15 at 12:48 pm SP#24 had a pain score of 7 and received dilaudid 1 mg IV. At 1:20 pm the patient # 24 had a pain score of 3.
The next pain assessment for SP#24 was on 5/18/15 at 8:05 pm which noted patient as anxious, grimacing, moaning with a pain scale of 10. SP#24 received Dilaudid 1 mg IV at 9 pm and had a pain level of 8.

Record review of the care plan for pain for SP#24 dated 5/7/15 revealed problem: pain related to cellulitis.
Expected goal: The patient will express relief / tolerance of pain.
Interventions: Assess and document pain upon admission and PRN which may include but not limited to character, duration, location, frequency of pain and vital signs. Utilize objective pain measurement scale 0 to 10 with 0 being no pain and 10 being maximum pain. Document trend and effectiveness of pain relief interventions. Assess and document patient response to medication and treatment therapies.

Interview on 5/22/15 at 10:23 am with the day shift oncology nurse for SP#24 revealed that she acknowledged that she didn't document her findings at the end of the shift. The day shift oncology nurse for SP#24 further read the care plan for pain and confirmed that she didn't follow the care plan for pain regarding assessment and documentation of pain.

Record review of the facility policy "Assessment and Management of Pain", (dated 1/12) note : Reassessment of pharmacological interventions will occur 30 minutes after IV or IM medication and 60 minutes after PO medications. Reassessment is a continuous process that is ongoing throughout the patients stay. Documentation of the reassessment of pain will be input into the electronic medical record prior to the end of the shift. All patients are reassessed at least every shift for pain as part of the ongoing reassessment process.

Based on record review and interview the facility failed to ensure that the nursing care plan for pain reassessments are conducted are planned based on the response to treatment of one (1) out of 13 sampled patients (SP). (SP#24)

The Findings:

Interview on 5/19/15 at 11:40 am SP#24 stated that he had a history of diabetes and wounds. The patient also stated, "I was in pain yesterday." He mentioned that a new IV was placed by the next shift nurse at 9 pm that night. He further stated that he had concerns about receiving his pain medication yesterday and also had concerns with his day shift nurse and that he had informed the charge nurse regarding this matter.

Record review of the physician admission assessment notes dated 5/7/15 showed that SP #24 was admitted with the assessment impression of lower extremity cellulitis, chronic pain syndrome.

Review of the physician orders for pain medications of SP#24 showed Fentanyl patch 75 mcg / hr topical extended release every 72 hrs. Tramadol 50 mg orally PRN (as needed) every 4 hrs. Percocet 5 / 325 mg orally every 4 hrs PRN. Dilaudid 1 mg IV push Q 4 hrs PRN.

Record review SP#24 Medication Administration Record (MAR) flow sheet for May 2015 revealed Fentanyl patch 75 mcg / hr was administered topically Q 72 hrs on 5/16/15 at 2:47 pm. This patch was re-administered on 5/19/15 at 3 pm. Dilaudid 1mg IV (intravenous) push PRN was administered on 5/18/15 at 3:08 am, 8:55 am, 12:48 pm and 9 pm.

Record review of SP#24 MAR dated 5/18/15 revealed there was no oral pain medication administration between 1 pm to 8 pm.

Record review of SP #24 pain assessment dated 05/18/15 showed that at 3:08 am the pain score was 7 at which time the patient received dilaudid 1 mg IV. The patient was not reassessed 30 minutes later according to the pain assessment documentation.

On 5/18/15 at 12:48 pm SP#24 had a pain score of 7 and received dilaudid 1 mg IV. At 1:20 pm the patient # 24 had a pain score of 3.
The next pain assessment for SP#24 was on 5/18/15 at 8:05 pm which noted patient as anxious, grimacing, moaning with a pain scale of 10. SP#24 received Dilaudid 1 mg IV at 9 pm and had a pain level of 8.

Record review of the care plan for pain for SP#24 dated 5/7/15 revealed problem: pain related to cellulitis.
Expected goal: The patient will express relief / tolerance of pain.
Interventions: Assess and document pain upon admission and PRN which may include but not limited to character, duration, location, frequency of pain and vital signs. Utilize objective pain measurement scale 0 to 10 with 0 being no pain and 10 being maximum pain. Document trend and effectiveness of pain relief interventions. Assess and document patient response to medication and treatment therapies.

Interview on 5/22/15 at 10:23 am with the day shift oncology nurse for SP#24 revealed that she acknowledged that she didn't document her findings at the end of the shift. The day shift oncology nurse for SP#24 further read the care plan for pain and confirmed that she didn't follow the care plan for pain regarding assessment and documentation of pain.

Record review of the facility policy "Assessment and Management of Pain", (dated 1/12) note : Reassessment of pharmacological interventions will occur 30 minutes after IV or IM medication and 60 minutes after PO medications. Reassessment is a continuous process that is ongoing throughout the patients stay. Documentation of the reassessment of pain will be input into the electronic medical record prior to the end of the shift. All patients are reassessed at least every shift for pain as part of the ongoing reassessment process.