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Based on clinical record reviews and interviews the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5) as evidenced by failure to assess pain level and failure to reassess effectiveness of pain interventions for 2 of 5 sampled patients (Patient # 7 and # 10) and failure to complete an initial nursing assessment for 1 of 7 sampled patients (Patient # 10) as specified per facility policies and procedures.


The findings include:


Facility policy titled "Pain Management" documents "Patients are assessed for the presence of recent history of pain during the patient assessment. When pain is identified, a more comprehensive pain assessment will be performed. Components of the pain assessment include, but are not limited to intensity, location, quality, exacerbating factors, alleviating factors, current pain medications and patients' pain goal. Pain is assessed using an objective rating scale according to developmental needs.
Management of Pain: When the patient reports an unacceptable level of pain, pain interventions will be instituted and documented on the medical record. As indicated, pain management strategies will be included in the individualized plan of care and documented on the interdisciplinary teaching record.
Reassessment of Pain: The efficacy of pain management interventions should be continually evaluated and adjusted based on the changing nature of pain. The pain intensity and pain relief as reported by the patient is reassessed and documented, after any known pain reducing event, with each report of pain, routinely at regular intervals, at least every shift and after each pain management intervention once a sufficient time has elapsed for the treatment to reach peak effect, but not to exceed two hours.

1) Clinical record review conducted on 04/24/14 revealed Patient # 10 was admitted to the facility on 10/25/13 for twenty three hour observation after a surgical procedure.

Post-Operative Physician's Orders dated 10/25/13 documents Hydromorphone 1 mg intravenously every three hours as needed for severe pain; Tylenol 1000 mg intravenously every six hours as needed for pain and Vicodin 5/500 mg by mouth every four hours as need for pain.

Medication Administration Record dated 10/25/13 thru 10/26/13 revealed Patient # 10 received pain medication as follows:
Hydromorphone 1 mg intravenously on 10/25/13 at 4:41 PM.
Vicodin 5/500 mg orally on 10/26/13 at 11:54 AM
Tylenol 1000 mg intravenously on 10/25/13 at 2:50 PM and 8:14 PM and on 10/26/14 at 2:17 AM and 8:10 AM.

Further review of the record failed to provide evidence Patient # 10 was assessed for pain as per facility policy prior to the medication administration/intervention on the days identified above. Furthermore, the record does not provide evidence the patient was reassessed to monitor the effectiveness of the interventions.

Interviews with The Director of Quality, The Director of Risk Management and The Director of Informatics conducted on 04/24/14 at approximately 11 AM verified the clinical record does not provide evidence of pain assessments and reassessments as identified above.


2) Interview with Patient # 7 conducted on 04/23/14 at approximately 1:45 PM revealed concerns related to pain management. The patient explained he was admitted to the facility for about ten days, was discharged home for one day and had to return to the hospital due to an infection. The nursing staff did not administer pain medication in a timely manner; took an average of an hour on most days. The patient stated the pain was not well managed; the medication given was not holding his pain and it took days for the dose to be increased despite multiple requests.

Clinical record review conducted on 04/23/14 revealed Patient # 7 was admitted to the facility on 04/10/14 and readmitted on 04/21/14 with multiple medical conditions.

Physician's Order dated 04/10/14 documents Percocet 5/325 mg one tab every four hours as needed for pain. Physician's Order dated 04/14/14 documents Percocet 10/325 mg one tab every four hours for severe pain.

The record revealed Patient # 7 was medicated for pain on 04/13/14 at 3:05 PM with Percocet 5 mg. At 7 PM the patient reported pain level of 9, the medication administration record indicates the patient was medicated for pain an hour later at 8:19 PM.

Medication Administration Record dated 04/10/14 thru 04/20/14 revealed Patient # 7 was medicated as follows:
Percocet 5/500 mg was administered on 04/11/14 at 1:30 PM; 04/12/14 at 3:45 AM; 04/13/14 at 4:15 AM; 04/16/14 at 10:45 AM and 04/18/14 at 9:02 PM. The record failed to provide evidence of pain assessment prior to the Percocet administration.

Further review of the record disclosed Patient # 7 was medicated for pain on 04/11/14 at 1:30 PM; 04/13/14 at 9:28 AM; 04/14/14 at 8:33 AM and on 04/16/14 at 10:45 AM. The record failed to provide evidence pain reassessment was conducted as per facility policy.

Interview with The Director of Quality Outcome and Director of Risk Management conducted on 04/24/14 at 12:15 PM confirmed the clinical record does not provide evidence of pain assessment and reassessment as indicated above.


3) Facility Policy Assessment and Reassessment documents " Each patient will have an initial assessment initiated no longer than 2 hours after admission and completed within 24 hours of patients arrival based on unit specific parameters and interdisciplinary variables. The initial assessment is documented in the clinical documentation system.


Clinical record review conducted on 04/24/14 revealed Patient # 10 was admitted to the Oncology floor on 10/25/13 at 1:45 PM.

Further review of the record revealed an initial nursing assessment was not initiated within two hours of admission. The first nursing assessment was documented at 9 PM.

Interviews conducted with The Director of Quality, The Director of Risk Management and The Director of Informatics conducted on 04/24/14 at approximately 11 AM revealed the nurse completed the admission history but did not document the nursing assessment.