HospitalInspections.org

Intakes: TN00035161

Based on policy review, record review and interview, it was determined the hospital failed to ensure nursing services appropriately assessed and followed up on pain interventions for 2 of 4 (Patients #1 and 2 ) sampled patients.

The findings included:

1. Review of the facility's "Assessment & Reassessment - Patient Guidelines" policy revealed, "...Reassessment determines the patient's response to care and treatment. Patient reassessment is ongoing...The patient assessment process is collaborative in order to facilitate, identify, and prioritize the patient's needs and determine care. The following variables influence and direct the process of patient assessment and reassessment...w. Pain: Onset and duration; location and radiation; description and intensity; factors that exacerbate or relieve...Reassessment includes but is not limited to review of the following parameters...(10) Pain - location, type, intensity, character..."

Review of the facility's "Pain Assessment and Management" policy revealed, "...Reassessment a. Pain rating reassessment will be completed after the administration of a pain medication...Reassessment will be documented in the patient's medical record...6. If pain interventions are ineffective (i.e. the patient does not experience pain relief and/or achieve an acceptable level of pain control), alternative orders for pain relief may be warranted and may require discussion with the physician. Alternative pain relief interventions may include, but are not limited to: a. Notifying physician of lack of pain relief or achieving pain rating and request for i. additional pain medication order ii. new or alternative orders for pain treatment..."

2. Medical record review revealed Patient #1 presented to the ER on 10/30/14 and admitted to the hospital on 10/31/14 with complaints of chest and shoulder pain.

Review of the physician's 10/31/14 order revealed Dilaudid 1 mg IVP every 4 hours as needed for pain.

Record review revealed on 11/10/14 at 1:15 PM the patient was administered Dilaudid 1 milligram (mg) for complaints of pain described as a 10 on a scale of 0 - 10, with 10 being the worst pain. A follow up assessment at 1:51 PM revealed the patient's pain was still at a level of 10.
There was no documentation the physician was notified of the patient's continued pain.

Record review revealed on 11/11/14 at 8:45 AM the patient was administered Dilaudid 1 mg for complaints of pain described as a level 10. A follow up assessment at 9:45 AM revealed the patient's pain was at a level of 9.
There was no documentation the physician was notified of the patient's continued pain.

During an interview on 4/7/15 at 2:00 PM the Chief Nursing Officer stated she would expect a reassessment within 30 minutes to an hour after pain medication was administered and if the pain was unrelieved to try an alternative intervention or call the physician.

3. Medical record review revealed Patient #2 was admitted to the hospital on 1/1/15 with the diagnosis of Right Flank Pain. The patient underwent surgery on 1/2/15 at 1:00 PM for a urethral stent placement.

Record review revealed on 1/2/15 at 5:19 PM the nurse administered Morphine 2 mg via IVP for pain.
There was no documentation the patient's pain location, description and intensity was assessed and documented in accordance with the facility's policy.