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Based on record review and interview the facility failed to assess and document a patient's pain level and provide appropriate pain management intervention when the patient complains of pain prior to being transferred from the hospital;

The facility failed to evaluate and document the patient's response to pain medication that was administered prior to her discharge from the hospital. Citing Patient (# 2) named in a complaint.

Findings:

Review of complaint narrative revealed allegations that Patient # 2 arrived at Q Nursing Home screaming from pain because Hospital (P) where she was a patient did not give her the pain medication she requested for her pain prior to sending her to a Nursing Home.

Review of history and physical dated 6/13/2015 revealed information the patient was admitted to the hospital with complaints she fell while getting in a truck and is having pain in her back and both knees.

Subsequent radiology examination revealed the patient had a right knee fracture. She was admitted to the post surgical unit for pain management and knee immobilization.

Review of nurses notes dated 7/8/2015 at 6:51 pm revealed information Patient # 2 complained of pain.

There was documentation the Tramadol was not due until 6:00 pm.

The Physician was informed and a one (1) time order of Tylenol 650 mg was administered to the patient at 4:52 pm.

There was no documentation the patient was assessed for severity of pain or evaluated for the patient's response to the medication that was administered.

Review of discharge records revealed the patient was discharged from the facility at 4:57 pm (two minutes after she received the Tylenol).


Review of medication administration records dated 6/13/2015 through 7/8/2015 9 revealed the patient was being treated with pain medication as follows:

Hydro/codone/APAP 10/325 one (1) tablet every four (4) hours as needed.(order discontinue 7/9/2015 due to discharge)

Tramadol 50 mg tablet every 6 hours as needed.

Duragesic Patch 50 microgram/Hr (fentanyl) as needed every three (3) days.

Flexeril 10 mg orally every eight (8) hours last given 7/4/2015 at 0626 am.


Review of discharge summary dated 7/8/2015 revealed the discharge plan for Patient (# 2) was to discharge the patient to a nursing home to continue pain management until the pain was sufficiently controlled for her to tolerate therapy.

During a telephone interview on 10/23/2015 at 9:15 am with Physician (#MJ ) he stated Tylenol was not sufficient pain medication for the patient because she had severe fracture pain.

He further stated there were standing orders that could have been given because the medications would not be discontinued until after the patient left the hospital.

During a interview on 10/23/2015 at 12:20 pm with the Chief Medical Officer he stated the patient's pain would not have been adequately managed with Tylenol.

He stated he would review the medical record and address the matter with Staff.
Review of the facility's Pain Management Guidelines dated March, 2015 revealed the following information:

"An appropriate pain scale rating will be utilized in conjunction with psychological data to guide pharmacological management of pain.

Effectiveness of pharmacological and non-pharmacological intervention will be evaluated within the appropriate time frames.

Pain should be reassessed after each pain medication administered. Pain assessment and reassessment must be documented."

Based on record review and interview the facility failed to develop a plan of care for a patient when the patient had a positive urine culture for E.Coli bacteria to ensure appropriate treatment intervention was implemented.

This failed practice resulted in the patient being discharged from the facility with an undiagnosed, untreated treated urinary tract infection(UTI). Citing Patient # 2 named in a complaint.


Findings:

Review of complaint narrative revealed allegations that Patient # 2 was transferred from Hospital P on 7/8/2015 to Q Nursing Home with an untreated urinary tract infection (UTI).

Review of history and physical dated 6/13/2015 revealed information the patient was admitted to the hospital with complaints she fell while getting in a truck and is having pain in her back and both knees.

Subsequent radiology examination revealed the patient had a right knee fracture. She was admitted to the post surgical unit for pain management and knee immobilization.


There was no history of fever or chills. Urinalysis revealed dark yellow urine clear in color. Genitourinary: No urinary symptoms. The patient was alert and oriented x 3.

Review of nurses notes dated 6/14/2015 revealed documentation that a Foley catheter was inserted,indication urinary retention and immobilization.

Nurses notes dated 6/28/2015 revealed documentation the patient's urine was cloudy and foul smelling.

Urine was sent to the laboratory for culture on 6/29/2015 and the Foley catheter was removed, (after being inplace for 15 days).

Review of the culture results revealed the urine was positive for E.Coli with a colony count greater that 100,000 colony forming units (cfu).

Review of Nurses notes dated 7/6/2015 revealed documentation A urine culture was done again on 7/6/2015 .

Review of the culture results revealed the urine was positive for E.Coli with colony count greater that 100,000 cfu.The Foley catheter was reinserted.


Review of physician's orders and progress notes dated 6/29/2015 through 7/8/2015 when the patient was discharged from the hospital revealed no documentation addressing the positive urine cultures.

Review of nursing care plans revealed a nursing care plan was not developed to address the positive urine cultures.

There was no documentation that the physician was informed of the first urine culture report.

Review of discharge plan and instructions dated 7/8/2015 revealed the positive urine cultures were not addressed.


Review of medication Administration record and treatment orders dated 6/13/2015-7/8/2015 revealed the patient was never given antibiotics or any other treatment for UTI.




During a telephone interview on 10/23/2015 at 9:25 am with Physician (#MJ) who attended Patient # 2 while she was in hospital, he stated the

chief focus of care for Patient # 2 was pain management for the multiple fractures she had.

He stated he coluld not recall what the colony count was for the urine but treatment would be considered for a colony count greater than 100,000.

During an interview on 10/23/2015 at 12: 25 pm with the Chief Medical Officer he stated the patient had a urine culture with a colony count greater
than 100,000 she should haven been treated for the Urinary Tract Infection (UTI).

During an interview on 10/23/2015 at 8:45 am with the Nurse Manager on the unit where Patient #2 was a patient she stated a nursing care plan

should have been developed to indicate the culture findings and the physician informed.