HospitalInspections.org

Based on policy and procedure review, patient medical record review, and staff interview, the director of nursing services failed to ensure the implementation of the documentation policy for 4 of 5 patients (#1, #2, #3, and #4); failed to implement the pain policy for two patients (#2 and #3); and failed to implement the policy related to the security of medications from home for one patient (#3).

Findings:
1. at 12:40 PM on 5/31/13, review of the policy and procedure "Documentation Standards: Inpatient", with a "File No.: NSP-152-P", and a general and content revision date of 10/23/12, indicated:
a. under section " III. Daily Assessment and Care Standards", it reads in item O. on page 10:
"Feedings/Nutritional Intake: 1. Document percentage of meal or snack eaten..."

2. review of patient medical records indicated:
a. pt. #1 lacked documentation related to the % of meals eaten for breakfast on 1/4/13
b. pt. #2 lacked documentation related to the % of meals eaten for dinner on 1/11/3 and breakfast on 1/13/13
c. pt. #3 lacked documentation related to the % of meals eaten for breakfast 1/9/13; dinner listed as a % of "0" (with no explanation given for the zero) on, 1/12/13; and no breakfast documentation on 1/13/13
d. pt. #4 lacked documentation related to the % of meals eaten for dinner on 1/8/13; breakfast on 1/9/13; lunch on 1/9/13; and breakfast on 1/13/13

3. interview with staff member #59, the inpatient nurse manager, at 12:30 PM on 5/31/13, indicated:
a. nursing staff failed to document the percent of meals eaten as listed in 2. above

4. at 12:40 PM on 5/31/13, review of the policy and procedure "Documentation Standards: Inpatient", with a "File No.: NSP-152-P " , and a general and content revision date of 10/23/12, indicated:
a. under section " II. Admission Standards " , on page 3., it reads in items A. and C.: " A. These elements are crucial to prompt and safe patient care and should be completed as soon as possible. 1. Allergies...3. Pain Assessment...C. Pain Assessment Assess patient for presence of pain and determine the patient ' s comfort goal on admission using appropriate pain scale to describe intensity... "

5. review of patient medical records indicated:
a. pt. #2:
A. had an EMR (electronic medical record) form completed that listed the patient ' s admission pain level and that the patient ' s " back " pain was " chronic "
B. lacked documentation during the assessment, by nursing staff, of the patient ' s " comfort goal "
C. had a notation of a default comfort goal of " 3 or less " on the electronic form

b. pt. #3:
A. was admitted with complaints of chronic pain
B. lacked completion by nursing staff of the EMR pain assessment form
C. lacked documentation by nursing staff of a " comfort goal " for the patient

6. interview with staff member #59, the inpatient nurse manager, at 10:50 AM on 5/31/13, indicated:
a. no EMR pain assessment form can be located for pt. #3, as should have been completed on admission
b. pts. #2 and #3 would have a " default " pain comfort goal of 3 or less due to the lack of completion by nursing staff of the EMR form

7. at 11:40 AM on 5/30/13, review of the policy and procedure " Pain Assessment and Management in Adults and Older Adults " , with a "File No.: NSP-81-P" , and a general revision and content revision date of 11/7/12, indicated:
a. under "Definitions:" on page 2, it reads: "...Pain Intensity Levels...C. Severe Pain: self-report of a 7-10 on a 0-10 numeric pain scale...Pain Goal - A goal set with the patient that allows the patient to accomplish activities that are important to his/her recovery or quality of life..."
b. under "Policy:" on page 2., it reads: "Patients can expect that their pain will be managed using the best evidence available related to their condition..."
c. under "Procedure:" , on page 3., it reads in section I.:
A. "1. Initial Pain Assessment - assessment and documentation of the presence or absence of pain...The RN (registered nurse) will discuss with and assist the patient/family to identify a Pain Goal using an appropriate intensity rating scale...A. Initial Pain Assessment to be completed: 1. On admission...2. with new onset of pain..."
d. under "Procedure" , on page 6., it reads in section IV.:
A. "Ongoing Pain Assessment...2. Chronic pain - a minimum of every 4 hours and as needed specific to patient condition..."
e. under "Reassessment" on page 6, it reads: "I. Re-assessment includes post-intervention pain effectiveness...after receiving opioid medication...D. Additional Interventions - If upon reassessment the patient's pain is not reduced, relieved or at their comfort-function goal; the RN will implement additional interventions or contact the patient's Licensed Independent Practitioner (LIP)..."

8. review of patient medical records indicated:
a. pt. #2:
A. was admitted on 1/7/13 with documentation of "chronic back" pain
B. lacked documentation during the assessment, by nursing staff, of the patient's "comfort goal" (making the default comfort goal 3 or less)
C. had physician orders for Ibuprofen 400 mg every 4 hours PRN (as needed) for pain/fever
D. had physician orders for Tramadol 50 mg 4 times daily PRN for pain
E. had physician orders for Acetaminophen 650 mg every 4 hours prn for pain/fever
F. was given medication (Tramadol) for pain at 5:10 PM on 1/7/13 for pain at a level of 9 and still complained of pain at level of 9 at 6:10 PM with no documentation of having offered other pain medications or of having notified the LIP for possible further orders/instructions
G. was given medication (Tramadol) at 11:05 PM on 1/7/13 with the next documented pain assessment at 6:00 AM on 1/8/13 when the patient rated their pain at "8" with Tramadol given at 8:23 AM
H. at 2:00 PM on 1/8/13, the patient rated their pain at "10" , but medication was not given until 7:54 PM (pain also at " 10 " at 6:00 PM)
I. at 2:00 PM and 6:00 PM on 1/9/13, the patient rated their pain at "9" with no medications given and no documentation of notification of the LIP
J. on 1/11/13 at 5:19 PM, the patient was given Tramadol for pain at a level of "10", with no follow up pain re-assessment documented until 10:00 AM on 1/12/13

b. pt. #3:
A. was admitted on 1/8/13 and lacked completion of the EMR pain assessment form
B. lacked documentation by nursing staff of a "comfort goal" for the patient
C. had physician orders for Nabumetone 500 mg BID (two times/day) prn pain
D. had physician orders for Hydrocodone-acetaminophen (Norco) 7.5/325 4 times daily prn pain
E. was given Norco at 11:57 PM on 1/8/13 (for pain rated at a level of " 10") with the next pain re-assessment at 8:33 AM when the patient was medicated with Norco again
F. on 1/10/13, the patient rated pain at "10" (9 on the MAR--medication administration record) at 9:24 AM with Norco given--at 10:24 AM documentation on the pain "flowsheet", the patient still rated pain at a level of " 9 " with no documentation of notification of the LIP for possible orders--the next pain medication given (Norco) was at 2:49 PM on 1/10/13
G. follow up to the 2:49 PM Norco was at 4:00 PM when the patient remained at a level of "8" and was at "10" at 8:29 PM when Norco was given
H. follow up to the 8:29 PM (1/10/13) Norco was not until 6:41 AM on 1/11/13 when the patient reported pain at " 8" (Norco was given at 6:41 AM) pain was still reported at " 8 " at 8:00 AM with medication not given until 11:52 AM--follow up to this pain medication was at 5:47 PM when the patient was given Norco for pain at a level of " 10 " --at 6:47 PM, the patient still rated pain at " 10 " with no documentation of notification of the LIP for other orders, if desired
I. pain was rated as " 8 " at 9:00 AM on 1/12/13 after Norco was given at 8:18 AM--the next re-assessment was at 2:05 PM when pain was " 9 " and Norco was given at 2:27 PM

9. interview with staff member #59, the inpatient nurse manager, at 10:50 AM on 5/31/13, indicated:
a. per the pain policy, patients with chronic pain are to be assessed for pain every 4 hours--this policy was not followed by nursing staff
b. nursing failed to offer other pain medications, when administered meds did not reduce the patient ' s reported level of pain, or to notify the LIP for other orders that might have assisted pts. #2 and #3 with pain reduction
c. it cannot be determined that nursing staff attempted to meet the default comfort goal of 3 or less for patients #2 and #3

10. at 2:35 PM on 5/30/13, review of the policy "Patient's Medications from Home" with a "File No.: PNS-26-P" , and a general revision and content revision date of 11/12/12, indicated:
a. under "Procedure:" , it reads on page 2., under section II.: "If the medication cannot be sent home within the shift of admission, it is to be sent to Security for storage...D. Nursing personnel will document the disposition of the medications in the electronic History and Screen record..." (which has a section at the bottom for documenting Medication Placed in secured Area, # of Pills, and RX#)

11. review of the medical record for pt. #3 indicated:
a. a "Patient Clothing Sheet" was completed on admission (and scanned into the medical record) that noted: " bag of pills to security"
b. the "Patient Clothing Sheet" had a listing of medications and the amounts present dated on 1/13/13 when the patient was being discharged
c. there was no electronic form "History and Screen" in the EMR

12. interview with staff member #59, the inpatient nurse manager, at 11:55 AM on 5/31/13 indicated:
a. there is no electronic form "History and Screen" in the EMR for pt. #3
b. the "History and Screen" form of the EMR has a section at the bottom of the form for "Medication Placed in secured Area" -- "# of Pills" -- and "RX#"
c. per facility policy, nursing should have completed the electronic document for "History and Screen" by listing all of the medications from home and counting pt. #3's medications prior to sending them for lock up in security