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Based on facility policy review, record review and interview, the hospital failed to ensure nursing staff provided ongoing pain assessments and provided interventions for all patients who were experiencing avoidable pain which was excruciating for 1 of 1 (Patient #1) sampled patients who was experiencing pain post surgery.

The failure of nursing services to provide interventions and take steps to manage patients with severe pain resulted in an IMMEDIATE THREAT to the health and safety of the patients in the hospital who experienced moderate to severe pain without nursing interventions.

The findings included:

Patient #1 was admitted to the hospital on 5/14/2021 for scheduled ventral hernia repair surgery. The patient subsequently had a total of 6 surgeries related to the hernia repair during the hospital admission and one (1) non-surgical procedure. The patient experienced severe pain following the surgeries and required intravenously narcotics for pain relief

On 6/3/2021 at 2:39 PM, Patient #1 was transferred from the Surgical Intensive Care Unit to the Medical Surgical Unit.

Review of the Medical Surgical Unit Medication Administration Record (MAR) and Nursing Pain Assessment revealed no pain medications were administered for 4 hours after Patient #1 had complained of pain. Patient #1 was discovered by the nursing staff grimacing, sweating and in severe pain prior to the administration of pain medication.
Refer to A395 for additional information regarding the lack of assessments and pain management for Patient #1.

Based on policy review, medical record review and interview, the hospital's nursing services failed to ensure that all patients' needs were met by ongoing assessments of patient's needs and took measures to ensure patients did not experience avoidable excruciating pain for 1 of 1 (Patient #1) patients reviewed who complained of severe pain post-operatively.

The findings included:

1. Review of the hospital's Pain Assessment and Management policy dated 1/11/18 and reviewed on 3/9/2021 revealed, "...Patient rights related to pain management...to have pain managed effectively...Nurse's caring for patients with pain should perform initial and ongoing assessments of pain and communicate assessment data to colleagues...Moderate Pain: (Tolerable pain that becomes intolerable and interferes with activities, Intolerable: interferes with most activities requiring physical exertion, but not passive activities...such as talking on the phone, watching TV, reading, use of computer)...Severe pain: (Intolerable interferes with all active and most passive activities, Intolerable patient is unable to do anything or even speak due to their pain)...Before administering pain medication the nurse should review prior pain medications the patient has received including medications given in other areas...Pain will be re assessed according to changes in the patient's condition as well as the patient's perception of pain. Nurses are responsible for identifying the problem of inadequate pain management in patients and for intervening responsibly to achieve the best level of pain control possible...[Patients]...have the right to pain management and the right to be actively involved in decision-making as appropriate in their pain management.

2. Medical record review for Patient #1 revealed a scheduled admission on 5/14/2021 for ventral hernia repair surgery. Patient #1 has a past medical history of obesity.

Patient #1's Surgical Procedures were as follows:
On 5/14/2021 Patient #1 had a complex ventral hernia repair and a closure with Prolene mesh (device to repair the hernia) and a wound drain was placed (wound drains are placed to remove any excess fluid/drainage from the surgical area post-operatively in order to prevent infections). Patient #1's post-op course was complicated by the discovery of a small bowel perforation which had occurred during surgery. The patient experienced gross spillage of succus (gastric fluid) throughout abdomen.

On 05/16/2021 Patient #1 underwent an a 2nd surgery for a small bowel perforation (hole in the bowel). During the surgical procedure the mesh was removed, abdomen cleaned, Lysis of Adhesions (procedure that destroys scar tissue that's causing abdominal pain) and Small Bowel Resection (removal of part of the bowel). Three (3) wound drainage systems were placed. Patient #1 was admitted to the hospital's Surgical Intensive Care Unit (SICU) following this surgery.

Review of Physician #1's progress note dated 5/16/2021 revealed Physician #1 documented patient remains critically ill with acute kidney injury and on significant pressure requirements, continue sedation with propofol and Fentanyl. Patient #1 was placed on ventilator.

On 05/23/2021 Patient underwent a 3rd surgical procedure for a small bowel perforation and repair. Post operatively the patient had an open abdominal dressing placement.

On 05/25/2021 Patient #1 underwent a 4th surgical procedure due to an anastomotic leak (an anastonomotic leak is drainage/leakage from the surgical site) and sepsis (a life-threatening bloodstream infection).

On 05/27/2021 Patient #1 underwent a 5th abdominal surgery due to sepsis. The patient's abdominal area was cleansed and closed with a temporary closure.

On 05/29/2021 Patient #1 underwent a 6th surgical procedure due to a history of an intra-abdominal abscess (infection) and an enterotomy (surgical incision in the bowel) and anastomotic leak. The patient's abdominal area was cleansed and closed.

On 06/09/2021 Patient #1 underwent a 7th procedure which was a Computerized tomography (CT) scan (a CT scan is a non-invasive procedure used to see images of the body) and guided drainage of abscesses in the Left Pelvic and Left Abdominal area.

3. Review of physician pain medication orders revealed the following orders for pain relief:
On 5/14/2021 at 11:53 AM Morphine 2 milligrams (mgs) Intravenous Push (IVP) every 1 hour was ordered as needed (PRN) for severe pain.
On 5/14/2021 at 11:53 AM Tramadol 50 mg 1 tab PO (by mouth) every 4 hours PRN was ordered for moderate pain.
On 5/14/2021 at 11:53 AM Toradol 30 mg was ordered IVP to be administered every 6 hours; with a stop date of 5/17/2021.
On 5/16/2021 at 8:32 AM Acetaminophen-hydrocodone (Norco 5 mg-325 mg oral tablet) 1 -2 tablets PO was ordered to be administered every 4 hours PRN moderate pain.
On 5/16/2021 at 8:32 AM, Morphine 4 mg IVP was ordered to be administered every 4 hours PRN for severe pain with a stop date of 5/21/2021.
On 5/16/2021 at 9:19 AM Fentanyl 25-100 micrograms (mcgs) IVP was ordered to be administered every 1 hour PRN for severe pain with a stop date of 5/21/2021.
On 5/16/2021 at 8:32 AM Acetaminophen 325 mg oral tablet 1-2 tbs PO was ordered to be administered every 4 hours PRN for mild pain.
On 5/21/2021 at 3:22 PM Hydromorphone (Dilaudid) 0.5 mg IVP was ordered to be administered every 3 hours PRN for severe pain with a stop date of 5/22/2021.
On 5/22/2021 at 6:36 PM Hydromorphone (Dilaudid) 1 mg IVP was ordered every 3 hours PRN for severe pain with a stop date 5/28/2021.
On 5/29/2021 at 1:07 PM Hydromorphone (Dilaudid) 1 mg IVP was ordered every 1 hour PRN for severe pain with a stop date 6/4/2021.
On 6/3/2021 at 4:09 PM Hydromorphone (Dilaudid) was ordered intravenously (IV) via a Patient Controlled Analgesia (PCA) pump, 30 milliliters (ml)/(0.5 mg) with a lock out interval of 30 minutes with a 4 hour limit of 4 mg, PRN for pain with a stop date 6/6/2021.

4. Review of the Medication Administration Records (MARs) from 5/14/2021 - 6/3/2021 revealed Patient #1 was administered Pain medications as ordered by the physician for mild to severe pain.

On 6/3/2021, the SICU Pain Assessment revealed Patient #1's pain assessment was documented as moderate to severe constant pain to the abdomen surgical site.

Review of the SICU MAR dated 6/3/2021 revealed Patient #1 was administered Dilaudid 1 mg IVP at the following times:
1:24 AM, for severe pain,
4:35 AM for severe pain,
8:11 AM for severe pain,
9:22 AM, for severe pain,
11:41 AM for severe pain and
1:11 PM for severe pain.

On 6/3/2021 at 2:39 PM Patient #1 was transferred to the Medical Surgical unit (The patient had last received pain medications for severe pain at 1:11 PM prior to transfer).

Review of the Medical/Surgical Pain Assessment dated 6/3/2021 at 2:50 PM revealed Nurse #1 documented the patient had "no" pain.

There were no other pain assessments from 2:50 PM - 5:45 PM.

On 6/3/2021 at 5:45 PM, Nurse #1 documented that Patient #1 was "grimacing, sweating" and pain was "severe" to the abdomen. The nurse documented on the MAR she administered Dilaudid IVP for the patient's pain (This was 4 hours and 34 minutes after the patient's last pain medications at 1:11 PM). There was no documentation of the IV site where the IV Dilaudid was administered. There was no documentation on the MAR of Patient #1's response to the pain medication administered to include Level of Consciousness, Respirations, Oxygen Saturation or effectiveness of the pain medication received.

Review of the Nursing Documentation form dated 6/3/2021 revealed there was no documentation Patient #1 had received Dilaudid 1 mg at 5:45 PM or the response or effectiveness of the medication.

Review of the Pain Assessment dated 6/3/2021 at 7:45 PM revealed Nurse #1 documented the patient reported severe pain.

On 6/3/2021 at 7:45 PM, Patient #1 was started on a Hydromorphone (Dilaudid), PCA, 30 milliliters (ml) via a PCA pump with a dose of 0.5 mg, and a lock out interval 30 minutes with 4 hour limit for severe pain. The PCA pump was discontinued on 6/6/2021 at 4:08 PM. Patient #1 was started back on IV pain medications as follows:
On 6/7/2021 at 11:08 AM Hydromorphone (Dilaudid) 0.5 mg was ordered IVP every 2 hours, PRN for severe pain, with a stop date of 6/9/2021.
On 6/9/2021 at 11:07 PM Hydromorphone (Dilaudid) 0.5 mg was ordered IVP every 2 hours PRN for severe pain with a stop date 6/11/2021.
On 6/11/2021 at 9:30 AM Hydromorphone (Dilaudid) 0.5 mg was ordered IVP every 2 hours PRN for severe pain with a stop date 6/14/2021.
On 6/13/2021 at 4:45 PM Toradol 30 mg was ordered IVP every 6 hours for moderate pain with a stop date pf 6/18/2021.
On 6/14/2021 at 11:21 AM Hydromorphone (Dilaudid) 0.5 mg was ordered IVP every 2 hours PRN for severe pain with a stop date 6/17/2021.

5. Review of a Social Services/Case Management note dated 6/3/2021 for Patient #1 revealed the case manager documented Patient #1 stated, "...pt [patient] upset after being moved out of ICU. Wife requesting someone follow up with patient...while at bedside, pt voiced concern stating ["I did not have a good transition"] from the ICU..." There was no documentation of the patients concerns.

6. During an interview in Patient #1's hospital room on 6/15/2021 when questioned about his hospital stay and his transition from the SICU to the medical-surgical unit Patient #1 stated, "...This was a big mistake. I shouldn't still be here. I came in for a simple hernia mesh replacement. They cut me in 2 different places. When I was transferred from ICU to here I had to wait 2 or more hours to get my pain medication. I was in a lot of pain...."
When asked what his pain level was on a scale from 1 -10 with 10 being the worst pain, Patient #1 stated his pain was an 8 or 9. Patient #1 stated, "... the nurse told me they didn't have pain medication on the floor [medical-surgical unit]...I asked for pain medication several times when I came to the floor [medical-surgical unit]. The nurse told me she had 5 other patients ahead of me. She said she didn't even know I was coming to the floor [medical-surgical unit]and she wasn't ready for me. She said she would have to go find orders. Another hour went by and she still hadn't brought me my pain med [medicine]. I called her again and then she finally brought it. I was really hurting by then. They gave me a machine where I could just hit a button and get my pain medicine. I think they said it was Dilaudid..."

During an interview in the conference room on 6/16 2021 at 1:20 PM when questioned about Patient #1 and the patient's pain medications Nurse #1 stated, "...he [Patient #1] had Dilaudid every hour ordered. I told him he was my 5th patient and it was a regular floor and I knew I wouldn't have time to come in every hour on the dot to give him pain meds..." Nurse #1 stated she did not remember what patient #1's pain level was on admission to the unit. Nurse #1 stated she contacted the physician to get an order for PCA and "We had to wait on pharmacy to bring it up [bring the PCA pump]".

Patient #1 was experiencing moderate to severe pain post six (6) surgical procedures and on (1) non-surgical procedure for a hernia repair with complications. Patient #1's pain was being assessed and treated with pain medications while in the SICU. Upon the patient's transfer from SICU to the medical-surgical unit there was a lapse in the patient receiving pain medications for 4 hours and 34 minutes. The patient was found by the nursing staff grimacing, sweating and severe pain. The patient was upset by this and the nurse's response was she was busy with other patients. The hospital failed to ensue patients did not suffer from excruciating, avoidable pain.