HospitalInspections.org

Based on review of documentation and interview with staff, it was determined that nursing staff failed to follow a physician's order to be notified if pain control was ineffective for patient #1.

Findings included:

A review of the medical record revealed patient #1 was admitted for uncontrolled pain after having back surgery on 12/12/11.

A review of the medical record revealed there was a physician's order dated on 12/12/2011 at 2:20pm. This order stated, "Notify staff member #2/staff member #1 if...pain not controlled with medications." The orders were signed by staff member #1. Staff member #2 was the surgeon for patient #1.

A review of the medical record revealed staff member #2 ordered on 12/14/2011 at 11:00am "DC /heplock IV's (intravenous) ...DC PCA (Pain Controlled Analgesia).., Lortab 7.5 mg/500 po (by mouth) q6 h (every 6 hours) PRN (as needed) pain..." At 12:00pm, a staff physician order revealed, "DC IVF (Intravenous Fluids)."

A review of the medical record revealed a telephone order dated 12/14/2011 at 3:00pm from physician #3 revealed "Dilaudid 1 mg IV q4 (every 4 hours) PRN, Dilaudid 2-4 mg po q6 (every 6 hours) PRN." Noted by a nurse and signed off by staff member #3 on 12/27/2011.

There was no documentation found in the medical record of patient #1 or provided to the surveyor to indicate that the nursing staff notified staff member #1 or staff member #2 that the patient was having problems with pain control as specified by the physician order dated 12/12/11.

In a telephonic interview on 4/3/12 at approximately 4:30pm with staff member #1, it was confirmed that the nursing staff did not notify either staff member #1 or staff member #2 that patient #1 was having problems with pain control. Staff member #1 stated staff member #2 wants to be notified when patients are having problems with pain control. Staff member #1 stated staff member #2 wants to manage the patients pain medications.

In an interview with staff member #4 on 4/3/12 at approximately 5:15pm, the above was confirmed. It was also confirmed in the same interview that staff member #2 did have the order to be notified if patient #1's pain was not controlled with pain medication. Staff member #1 or staff member #2 was not notified and pain medication was prescribed to patient #1 without the consultation of staff member #1 or staff member #2. Staff member #4 also stated the nursing staff was now aware that staff member #2 wants to be notified when any patients are having problems with pain control.