HospitalInspections.org

Based on review of facility policy, medical record review, and interview, the facility failed to follow a physician's order for administration of an Patient Controlled Analgesia (PCA) pump for 1 patient (#1) of 2 patients reviewed for PCA pumps.

The findings included:

Review of facility policy "PCA" last revised 12/2016 revealed "...it shall be the policy of this hospital to provide pain relief for patients in accordance with physician's orders and Health System policies..." Further review revealed "...if ordered by physician, begin continuous measurement of exhaled carbon dioxide [SpO2]...assess and document vital signs and PCA assessment including EtCo2 [End Tidal Carbon Dioxide] or SpO2 [when indicated] readings at the time if starting infusion..."

Medical record review revealed Patient #1 was admitted to the facility on 12/12/16 with diagnoses including Ileocolic Stricture Secondary to Crohn's Disease (chronic inflammatory bowel disease) and a Partial Colectomy (removal of partial side of colon) with Ileocolic Anastomosis. Further review revealed the patient was discharged home on 12/15/16.

Medical record review of the Admission Post-Operative Orders dated 12/12/16 revealed "...Dilaudid [pain medication] PCA 0.4 mg [milligrams] IV [intravenous] q [every] 6 minutes PRN [as needed] for pain...OK for 1 mg loading dose PRN...20 mg with 4 hour lockout...place patient on EtCO2..."

Medical record review of a Physician's Order dated 12/13/16 at 9:00 AM revealed "...d/c [discontinue] EtCO2 monitor, use continuous pulse oximetry instead...Percocet [oral pain medication] 10/325 mg one PO [by mouth] every 4 hours PRN for pain..."

Medical record review of a Respiratory Therapy note dated 12/13/16 at 9:45 AM revealed "...called to pt.'s room due to EtCO2 alarm going off. Pt. did not want to keep the cannula in...stated [named physician] told him he did not have to wear it..attempted to put cannula back on pt. [patient] and he took it off and said he would not use to just take pain pump out. RN [Registered Nurse] had already called CNO [Chief Nursing Officer] to come to the room..."

Medical record review revealed no documentation of a Physician's order to discontinue the PCA pump.

Medical record review of a Nurses Note dated 12/13/16 at 11:50 AM revealed "...requesting more pain medication. Called [named physician]...said put back on PCA without EtCO2. Called [named Director of Medical Surgical unit] d/t [due to] pt. is required to have EtCO2 per hospital policy..."

Medical record review of a Nurses Note dated 12/13/16 at 11:51 AM revealed "...explained to patient he could have PCA pump back with EtCO2 monitor and he refused d/t required EtCO2 monitor..."

Medical record review of a Nurses Note dated 12/13/16 at 1:35 PM revealed "...requesting pain medication, explained to patient that not enough time has elapsed for Percocet and to reorder PCA pump, the EtCO2 would have to be used..."

Medical record of a Nurses Note dated 12/13/16 at 2:55 PM revealed "...PCA was started without EtCO2 per [named physician] order. CNO and CEO [Chief Executive Officer] informed..."

Medical record review of the MAR dated 12/13/16 revealed the patient received Dilaudid 2 mg IVP [intravenous push] at 3:15 PM.

Medical record review of a Physicians Progress note dated 12/13/16 at 5:05 PM revealed "...patient seen and examined by me. Upset about 6 hour and 40 minutes delay in pain meds tx [treatment]...acknowledged by me...o/w [other wise] pain presently well controlled..."

Medical record review of a Discharge Summary dated 12/15/16 at 8:40 AM revealed "....the patient had an uneventful recovery except that his PCA was discontinued at some point during his stay in advertently by the nursing staff and did not get restarted for about 6 hours and 40 minutes. During that time the patient was under extreme duress and a lot of pain. We tried multiple attempts to redirect the nursing staff to restart his narcotic prescriptions and this was met with failure and resistance from the nursing staff based on some policy guidelines that they felt like conflicted with the physician's orders. Eventually, it was restarted under the newly prescribed orders and the patient thereafter had an uneventful stay...was deemed fit enough for discharge to home..."

Interview with the Interim Chief Nursing Officer (CNO), on 3/7/17 at 11:30 AM, in the CNO's office, revealed the patient requested to review his medical record a few weeks ago. The patient had come to the facility where the nursing staff had gone over the medical record and answered the patient's questions. Further interview revealed "...he had questions why his PCA pump was stopped and insisted his pain was not controlled for several hours...there is no documentation regarding the exact time PCA was stopped...the policy does not state the EtCO2 has to be in place if a PCA pump is used..." Further interview revealed "...it is my understanding the nurse had called for the (former) CNO to come up to the floor when the patient did not want the End Tidal Co2 on and the physician was very upset..." Further interview revealed "...the CNO told the patient the PCA could not be continued without the CO2 monitor in place due to hospital policy and the patient had told them to take it off..." Further interview confirmed there was no order to discontinue the PCA pump and no documentation the physician was notified when the PCA was discontinued.

Interview with the Emergency Department (ED) Director on 3/7/17 at 1:05 PM, in the CNO 's office, revealed the nurse had reviewed the medical record with the patient a few weeks ago. Further interview revealed "...the patient wanted to see the physician's orders to discontinue the pump, the physician's progress notes, the medication administration records, and the nurses notes...the patient said his PCA pump was stopped and he was in a lot of pain..." Further interview confirmed ..."there was no order to discontinue the pain pump..."

Telephone interview with RN #1 on 3/8/17 at 2:45 PM, revealed the nurse provided care to the patient on 12/13/16. Further interview revealed the patient was on a PCA pump after surgery. Continued interview revealed "...[named physician] wrote an order to discontinue the End Tidal CO2 monitor and put a pulse oximeter on the patient...I called for the CNO to come to the floor due to [named Director] was not on the floor..." Further interview revealed "...I called [named CNO] and she came into the patient's room...she told him he could not have the PCA if the End Tidal CO2 monitor was not in place per hospital policy...she told him the only thing we could do was to discontinue the PCA and the patient said take it off...she told me to take it off...I am not sure what time it was and I do not see that I had documented it...I never got an order to discontinue the PCA..." Further interview confirmed there was no order to discontinue to the PCA pump.

Interview with Patient #1's physician on 3/8/17 at 4:20 PM, in the CNO's office, revealed the physician had ordered the PCA pump for the patient post-operatively. Further interview revealed "...I saw this patient around 9:00 AM on December 13th and he was complaining the monitor had kept him awake all night and stated he just needed to sleep. I told him we could take the monitor off and use pulse oximetry to ensure his respiratory status..." Further interview revealed "...I wrote an order to d/c the CO2 detector and for PO Percocet for break through pain...I did not write an order to d/c the PCA pump...I talked to [named RN] and told her exactly what I wanted and she understood that..." Further interview revealed "...the nurse called me around 12:00 PM and told me the PCA had been discontinued due to hospital policy regarding the CO2 monitor and the CNO had told her to stop the PCA...they did not put the pulse oximeter on the patient...I told her to start the PCA back and follow the order as I had written it...once the PCA was restarted the patient's pain was controlled...it was 6 hours and 40 minutes the patient was off the pain pump...I was not called and told the pain pump was discontinued..." Further interview confirmed the physician did not give an order for the PCA to be discontinued.

Telephone interview with the former CNO on 3/8/17 at 5:04 PM revealed "...I went in and talked to the patient and told him we wanted his pain controlled...I was told the PCA pump was going to be weaned and discontinued...he had an order for PO pain meds..." Further interview revealed "...I did not tell the nurse to discontinue the pump...I told her to watch the patient's pain levels and administer the pain meds as ordered..." Further interview revealed "...the nurse said it was policy to place an End Tidal CO2 detector on patients with a PCA pump but the physician had told her take it off...I just told her to follow the physicians orders..." Further interview confirmed there was no order to wean or discontinue the PCA pump.