HospitalInspections.org

Based on interview and record review, the facility failed to ensure that the Condition of Participation for Governing Body was met as evidenced by:

1. The facility failed to ensure that the contracted furnisher of dialysis services provided dialysis (removal of excess toxins from the blood in people whose kidneys can no longer perform this function naturally) treatment in accordance with facility policy, procedure, and contract agreement for five of eight patients (Patients 1, 2, 3, 4, and 5). (Refer to A-0083)

2. The facility failed to ensure that dialysis patients received dialysis treatment as ordered by the physician for five of eight patients (Patients 1, 2, 3, 4, and 5). (Refer to A-0083)

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver care in compliance with the Condition of Participation: Governing Body.

Based on interview and record review, the facility failed to:
1. Ensure that the contracted furnisher of dialysis services provided dialysis (removal of excess toxins from the blood in people whose kidneys can no longer perform this function naturally) treatment in accordance with facility policy, procedure, and contract agreement for five of eight patients (Patients 1, 2, 3, 4, and 5).
2. Ensure that dialysis patients received dialysis treatment as ordered by the physician for five of eight patients (Patients 1, 2, 3, 4, and 5).

This failure had the potential to result in harm due to complications of a delayed dialysis treatment. This deficiency also led to:
a. Patient 1 being prematurely discharged (when patient is discharged too early) to receive dialysis treatment at an outside dialysis center.
b. Patient 2 received dialysis treatment more than 15 hours after physician order for hemodialysis.
c. Patient 3 sustained mental status changes concerning for dialysis disequilibrium syndrome (a rare but serious complication of hemodialysis) and a rapid response was called on 2/5/2022.
d. Patient 4 received dialysis treatment two (2) days after physician order for hemodialysis.
e. Patient 5 received dialysis treatment two (2) days after physician order for hemodialysis.

On 6/9/2022, at 3:42 p.m., an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Patient Safety Officer (PSO), Director of Quality Improvement (DQI), Chief Nursing Officer (CNO), and Vice President of Quality (VPQ). The survey team notified the hospital leadership about the IJ situation regarding the failure to ensure that the contracted furnisher of dialysis services provided dialysis treatment in accordance with facility policy, procedure, and contract agreement.

On 6/10/2022, at 12:29 p.m., the IJ was removed in the presence of the facility's PSO, DQI, and CNO after the survey team validated the hospital's directive action plan through observations, interviews, and limited record reviews.

Findings:

a. A review of Patient 1's History and Physical (H&P), dated 12/24/2021, indicated that Patient 1 was admitted on 12/23/2021 due to sepsis (the body's overwhelming and life-threatening response to infection that can lead to organ failure and death) with fever and abdominal pain likely secondary to spontaneous bacterial peritonitis (SBP - an infection of abdominal fluid). Patient 1 also had end stage renal disease (ESRD - a medical condition in which a person's kidney cease functioning on a permanent basis) and required peritoneal dialysis (a way to remove waste products from the patient's blood when the kidneys cannot adequately do the job any longer; a cleansing fluid flows through a tube into part of the abdomen).

A review of Patient 1's Order, titled "Plans of Care," indicated that the physician ordered peritoneal dialysis on 12/24/2021 at 12:19 a.m.

A review of Patient 1's Nursing Note, dated 12/24/2021, at 4:46 a.m., indicated the facility's contracted dialysis company was called for "peritoneal dialysis today."

A review of Patient 1's Nursing Note, dated 12/24/2021, at 10:30 a.m., indicated dialysis "will not be done until tonight."

A review of Patient 1's Consultation Note, dated 12/24/2021, indicated Patient 1 "continues to complain of marked abdominal discomfort." The Consultation Note indicated, "Will get dialysis for [Patient 1] as soon as possible for relief of [Patient 1's] abdominal pain and treatment of [Patient 1's] acute peritonitis (redness and swelling of the lining of the belly or abdomen). The Consultation Note also indicated that the physician notified the facility's contracted dialysis company at 7:40 a.m. to inform them of "the need for urgent peritoneal dialysis for treatment of [Patient 1's] acute peritonitis" and notified the facility's contracted dialysis company's nurse at 8:30 a.m. of "the need for urgent dialysis."

A review of Patient 1's Nephrology Consultation Note, dated 12/24/2021, indicated the contracted dialysis company "was unable/unwilling to perform peritoneal dialysis for [Patient 1] in a timely fashion" ... Patient 1 "required washout intraperitoneal (procedure in which a salt-water solution is used to wash the peritoneal cavity [space in the abdomen that contains the intestines, stomach, and liver] and then is removed) antibiotics as soon as possible." The Consultation Note further indicated that Patient 1's care would be compromised if Patient 1 did not get urgent peritoneal dialysis. The Nephrology Consultation Notes further indicated that MD 2 felt that patient would then be served best by discharging her (Patient 1) to an outpatient dialysis center which can administer the intraabdominal antibiotics during her (Patient 1) peritoneal dialysis.

A review of Patient 1's Discharge Summary, dated 12/24/2021, indicated Patient 1's nephrologist (doctor who specialize in conditions that affect the kidney) "felt that the best course of treatment was dialysis with intraabdominal antibiotic administration and washout ... We were unable to obtain dialysis services in a timely manner in the hospital."

During a concurrent interview and record review on 6/8/2022, at 3:12 p.m., with Patient Safety Officer (PSO), Patient 1's medical records were reviewed for the facility form titled, "Hemodialysis Nursing Notes." PSO stated "Hemodialysis Nursing Notes" are used to document dialysis treatment start and end time. PSO stated that the "Hemodialysis Nursing Notes" form was not in Patient 1's medical records. PSO stated dialysis was not completed for Patient 1 from Patient 1's admission to the hospital on 12/23/2021 at 11:55 p.m. until discharge from the hospital on 12/24/2021 at 1:36 p.m.

During an interview on 6/8/2022, at 4:29 p.m., with Manager of Resource Center (MRC), MRC stated potential patient outcomes for missed dialysis treatment can include patient deterioration (process of becoming progressively worse) and hemodynamic instability (abnormal or unstable blood pressure, which can cause inadequate blood flow to the organs).

A review of the facility's contract with the dialysis company, titled "Dialysis Services Agreement," effective 2/1/2020, indicated, "Contractor will make available Contractor Providers to provide non-emergency dialysis services as requested by Hospital. Contractor will also make Contractor Providers available for the provision of emergency dialysis services. Contractor shall require a Contractor Provider to present to Hospital within 120 minutes of Hospital's request for emergency dialysis service."

A review of the facility's policy and procedure (P&P), titled "Hospital Plan for the Provision of Patient Care Services," dated 9/2020, indicated the purpose of the P&P was "the hospital plan for the provision of patient care is the framework for defining the delivery of patient care at [facility]." The P&P also indicated, "Patient care is based on an interdisciplinary assessment of the patient's relevant physical, psychological, social, educational, and environmental status determining the patient's health care needs ... and timely response to changing patient needs ..." The P&P also indicated, "Patient services occur through organized and systemic processes that are designed to ensure safe, effective, timely care and treatment."

b. A review of Patient 2's History and Physical (H&P), 1/20/2022, indicated that Patient 2 was admitted on 1/20/2022 due to sepsis (the body's overwhelming and life-threatening response to infection that can lead to organ failure and death) secondary to coronavirus (COVID-19, a new respiratory virus that can spread from person to person) pneumonia (lung inflammation caused by bacterial or viral infection). Patient 2 also had acute kidney injury (a condition in which the kidneys suddenly cannot filter waste from the blood) with chronic kidney disease stage 3 (indicates moderate kidney damage and noticeable loss of kidney function).

A review of Patient 2's Nursing Note, dated 2/11/2022, at 11:04 a.m., indicated the contracted dialysis company was notified of dialysis orders for 2/12/2022 and 2/14/2022.

A review of Patient 2's Nursing Note, dated 2/12/2022, at 8:09 a.m., indicated the contracted dialysis company was made aware of hemodialysis order "for today 02/12."

A review of Patient 2's Order Information for Hemodialysis indicated a requested start date and time of 2/12/2022 at 9:00 a.m.

A review of Patient 2's Nursing Note, dated 2/12/2022, at 11:58 a.m., indicated the contracted dialysis company was contacted and was "waiting for call back concerning appointment time."

A review of Patient 2's Nursing Note, dated 2/13/2022, at 1:01 a.m., indicated the contracted dialysis company was contacted and "no ETA (estimated time of arrival) given."

A review of Patient 2's Nursing Note, dated 2/13/2022, at 4:09 a.m., indicated the contracted dialysis company was contacted regarding dialysis order for Patient 2.

A review of Patient 2's Nursing Note, dated 2/13/2022, at 11:58 a.m., indicated the contracted dialysis company was notified that Patient 2's "HD (hemodialysis) order for yesterday, 2/12/22 has not been done."

A review of Patient 2's Nephrology Progress Note, dated 2/13/2022, indicated, "[Patient 2] did not get [Patient 2's] dialysis yesterday (2/12/2022) ...".

A review of Patient 2's Hemodialysis Nursing Notes, dated 2/13/2022, indicated the hemodialysis order was initiated on 2/13/2022 at 1:30 p.m.

During an interview on 6/8/2022, at 4:19 p.m., with Manager of Resource Center (MRC), MRC stated, non-emergency order response expectation from the contracted dialysis company is within 24 hours between physician order and start of treatment. MRC stated the hemodialysis order placed on 2/12/2022 at 9:00 am should have been initiated by 2/13/2022 at 9:00 am, within 24 hours of order. MRC stated the potential patient outcome for missed or delayed hemodialysis treatment order can include patient deterioration (process of becoming progressively worse) and hemodynamic instability (abnormal or unstable blood pressure, which can cause inadequate blood flow to the organs).

A review of the facility's contract with the dialysis company, titled "Dialysis Services Agreement," effective 2/1/2020, indicated, "Contractor will make available Contractor Providers to provide non-emergency dialysis services as requested by Hospital. Contractor will also make Contractor Providers available for the provision of emergency dialysis services. Contractor shall require a Contractor Provider to present to Hospital within 120 minutes of Hospital's request for emergency dialysis service."

A review of the facility's policy and procedure (P&P), titled "Hospital Plan for the Provision of Patient Care Services," dated 9/2020, indicated the purpose of the P&P was "the hospital plan for the provision of patient care is the framework for defining the delivery of patient care at [facility]." The P&P also indicated, "Patient care is based on an interdisciplinary assessment of the patient's relevant physical, psychological, social, educational, and environmental status determining the patient's health care needs ... and timely response to changing patient needs ..." The P&P also indicated, "Patient services occur through organized and systemic processes that are designed to ensure safe, effective, timely care and treatment."

c. A review of Patient 3's History and Physical (H&P), dated 2/1/2022, indicated Patient 3 was admitted on 2/1/2022 for a left hip fracture due to falling at home. Patient 3 also had ESRD, secondary parathyroidism (a condition where the parathyroid glands become enlarged and release too much of a hormone that controls the level of calcium in the blood), and hyperphosphatemia (too much phosphorus in the blood). Patient 3 reported receiving dialysis on Mondays and Fridays but missed scheduled treatment on 1/31/2022 due to the injury.

A review of Patient 3's Nursing Note, dated 2/2/2022, at 6:35 p.m., indicated the contracted dialysis company was made aware of a physician order for hemodialysis for 2/3/2022.

A review of Patient 3's Nephrology Progress Note, dated 2/3/2022, indicated that Patient 3 was "pending HD today."

A review of Patient 3's Nursing Note, dated 2/3/2022, at 7:50 a.m., indicated that the contracted dialysis company was contacted regarding the hemodialysis order for that day.

A review of Patient 3's Nursing Note, dated 2/3/2022, at 1:20 p.m., indicated that the contracted dialysis company was contacted regarding the hemodialysis order for that day. The Nursing Note further indicated that the contracted dialysis company's hemodialysis nurse was "already notified and [Patient 3 was] scheduled for today."

A review of Patient 3's Nursing Note, dated 2/4/2022, at 10:40 p.m., indicated that the contracted dialysis company called Patient 3's nurse at 8:09 p.m. "to say that the dialysis nurse has [Patient 3] on schedule and should be coming by but not able to provide ETA." The Nursing Note further indicated that the nurse called the contracted dialysis company back at 9:43 p.m. to update them on "patient's condition including mental status, lab results, increasing [blood pressure]." The contracted dialysis company stated they "will send dialysis nurse when possible."

A review of Patient 3's Nursing Note, dated 2/5/2022, at 1:09 a.m., indicated that Patient 3 developed altered mental status and that the physician was aware "that [Patient 3's] scheduled hemodialysis has been delayed for 2 days. RN called [contracted dialysis company] multiple times and updated them on patient condition."

A review of Patient 3's Rapid Response Note, dated 2/5/2022, at 4:16 p.m., indicated that on 2/4/2022, Patient 3 was reported to have "mental status change ... forgetting [Patient 3's] own birth year and having repetitive speech. This morning, [Patient 3] was AOx2 [alert and oriented to self and place, meaning the person only knows who they are and where they are but not what the date or time is], suspected due to not receiving dialysis for 1 week. At [2:00 p.m.], RN noted that patient was having new mental status changes, not responding appropriately, no answering questions, and having trembling movements in her right hand."

A review of Patient 3's Hemodialysis Nursing Notes, dated 2/5/2022, indicated Patient 3 began receiving hemodialysis that day at 11:30 a.m.

A review of Patient 3's Nephrology Progress Note, dated 2/5/2022, indicated that Patient 3 received dialysis earlier that day (2/5/2022). The Progress Note further indicated, "The dialysis nurse describes [Patient 3] as appropriate, awake, and alert, but the floor nurse disputes this assessment ... At present, [Patient 3] does not respond appropriately to me and does not follow commands ... [Patient 3] has developed altered mental status of unclear etiology [unclear what the cause is]. Dialysis dysequilibrium syndrome is possible."

A review of Patient 3's Nephrology Progress Note, dated 2/6/2022, indicated, "[Patient 3's] altered mental status pre-dialysis was likely related to metabolic encephalopathy (altered in mental status due to chemical changes in the brain) ... The worsening of her mental status with dialysis was likely due to dialysis disequilibrium syndrome, as she had not had dialysis for some time."

During a concurrent interview and record review on 6/8/2022, at 3:35 p.m., with Manager of Resource Center (MRC) and Risk Manager (RM), Patient 3's hemodialysis orders, dated 2/2/2022, were reviewed. RM confirmed that the hemodialysis order was placed on 2/2/2022 at 3:00 p.m. requesting for treatment to be conducted on 2/3/2022 at 9:00 a.m. MRC confirmed that hemodialysis was not initiated until 2/5/2022 at 11:30 a.m.

During an interview on 6/8/2022, at 4:29 p.m., with MRC, MRC stated potential patient outcomes for missed dialysis treatment can include patient deterioration (process of becoming progressively worse) and hemodynamic instability (abnormal or unstable blood pressure, which can cause inadequate blood flow to the organs).

A review of the facility's contract with the dialysis company, titled "Dialysis Services Agreement," effective 2/1/2020, indicated, "Contractor will make available Contractor Providers to provide non-emergency dialysis services as requested by Hospital. Contractor will also make Contractor Providers available for the provision of emergency dialysis services. Contractor shall require a Contractor Provider to present to Hospital within 120 minutes of Hospital's request for emergency dialysis service."

A review of the facility's policy and procedure (P&P), titled "Hospital Plan for the Provision of Patient Care Services," dated 9/2020, indicated the purpose of the P&P was "the hospital plan for the provision of patient care is the framework for defining the delivery of patient care at [facility]." The P&P also indicated, "Patient care is based on an interdisciplinary assessment of the patient's relevant physical, psychological, social, educational, and environmental status determining the patient's health care needs ... and timely response to changing patient needs ..." The P&P also indicated, "Patient services occur through organized and systemic processes that are designed to ensure safe, effective, timely care and treatment."

d. A review of Patient 4's History and Physical (H&P), dated 2/6/2022, indicated that Patient 4 was admitted to the facility on 1/12/2022 for a coronary artery bypass graft (CABG - a surgery to restore normal blood flow to the heart due to an obstructed artery). Patient 4 developed acute kidney injury post-operatively and began receiving dialysis. Patient 4 then transferred to the acute rehabilitation unit (ARU) on 2/5/2022.

A review of Patient 4's Nephrology Progress Notes, dated 2/6/2022, indicated that Patient 4 reported feeling weak. The Progress Notes further indicated that Patient 4 had "evidence of pulmonary fluid overload [too much fluid in the lungs]" and the nephrologist's suggestion was "dialysis today with additional fluid removal."

A review of Patient 4's Physician Orders, dated 2/6/2022, at 9:23 a.m., indicated that the nephrologist ordered hemodialysis for Patient 4 to begin at 10:00 a.m. that day.

A review of Patient 4's Nephrology Progress Note, dated 2/7/2022, indicated Patient 4 "has not received dialysis that was ordered for yesterday." The Progress Note further indicated that the plan was to "continue to try and get [Patient 4] dialysis ASAP."

A review of Patient 4's Nephrology Progress Note, dated 2/8/2022, indicated Patient 4 "has missed dialysis - was to be done 2/6 and yet to be done." The Progress Note further indicated the plan was to make sure dialysis was done that day and "will also order [dialysis] tomorrow as [Patient 4] is quite fluid overloaded."

A review of Patient 4's Hemodialysis Nursing Notes, dated 2/8/2022, indicated Patient 4 began receiving hemodialysis that day at 3:03 p.m.

During a concurrent interview and record review on 6/8/2022, at 3:35 p.m., with MRC and RM, Patient 4's hemodialysis orders, dated 2/6/2022, were reviewed. RM confirmed that the hemodialysis order was placed on 2/6/2022 at 9:23 a.m. requesting for treatment to be conducted the same day at 10:00 a.m. MRC confirmed that hemodialysis was not initiated until 2/8/2022 at 3:03 p.m.

During an interview on 6/8/2022, at 4:29 p.m., with MRC, MRC stated potential patient outcomes for missed dialysis treatment can include patient deterioration and hemodynamic instability.

A review of the facility's contract with the dialysis company, titled "Dialysis Services Agreement," effective 2/1/2020, indicated, "Contractor will make available Contractor Providers to provide non-emergency dialysis services as requested by Hospital. Contractor will also make Contractor Providers available for the provision of emergency dialysis services. Contractor shall require a Contractor Provider to present to Hospital within 120 minutes of Hospital's request for emergency dialysis service."

A review of the facility's policy and procedure (P&P), titled "Hospital Plan for the Provision of Patient Care Services," dated 9/2020, indicated the purpose of the P&P was "the hospital plan for the provision of patient care is the framework for defining the delivery of patient care at [facility]." The P&P also indicated, "Patient care is based on an interdisciplinary assessment of the patient's relevant physical, psychological, social, educational, and environmental status determining the patient's health care needs ... and timely response to changing patient needs ..." The P&P also indicated, "Patient services occur through organized and systemic processes that are designed to ensure safe, effective, timely care and treatment."

e. A review of Patient 5's History and Physical (H&P), dated 1/29/2022, indicated that Patient 4 was admitted to the facility on 1/29/2022 for a urinary tract infection and COVID-19. Patient 4 also had ESRD and was on hemodialysis.

A review of Patient 5's Nephrology Consultation, dated 1/29/2022, indicated that Patient 5 began receiving hemodialysis in 2021 and dialyzed twice a week at an outpatient dialysis facility. The Consultation further indicated that the nephrologist recommended hemodialysis for that day.

A review of Patient 5's Physician Orders, dated 1/29/2022, at 1:19 p.m., indicated that the nephrologist ordered hemodialysis for Patient 5 to begin at 3:00 p.m. that day.

A review of Patient 5's Nursing Note, dated 1/29/2022, at 2:19 p.m., indicated that the contracted dialysis company was contacted for Patient 5's ordered dialysis.

A review of Patient 5's Nephrology Progress Notes, dated 1/30/2022, indicated, "[Patient 5] needs dialysis today, RN has once again called [contracted dialysis company]."

A review of Patient 5's Nephrology Progress Notes, dated 1/31/2022, indicated, "[Patient 5] was first seen at [facility] late on January 28, 2022 because [Patient 5] was unable to get dialysis at the dialysis center as [Patient 5] was not feeling well. Dialysis was ordered on january 29 but not provided. Dialysis was ordered again on January 30 but not given to him. Today, [Patient 5] is more uremic [having abnormally high levels of waste products in the blood]."

A review of Patient 4's Hemodialysis Nursing Notes, dated 1/31/2022, indicated Patient 5 began receiving hemodialysis that day at 4:43 p.m.

During an interview on 6/8/2022, at 4:29 p.m., with MRC, MRC stated potential patient outcomes for missed dialysis treatment can include patient deterioration and hemodynamic instability.

During a concurrent interview and record review on 6/8/2022, at 4:39 p.m., with MRC and RM, Patient 5's hemodialysis orders, dated 1/29/2022, were reviewed. RM confirmed that the hemodialysis order was placed on 1/29/2022 at 13:19 p.m. requesting for treatment to be conducted the same day at 3:00 p.m. MRC confirmed that hemodialysis was not initiated until 1/31/2022 at 4:43 p.m.

A review of the facility's contract with the dialysis company, titled "Dialysis Services Agreement," effective 2/1/2020, indicated, "Contractor will make available Contractor Providers to provide non-emergency dialysis services as requested by Hospital. Contractor will also make Contractor Providers available for the provision of emergency dialysis services. Contractor shall require a Contractor Provider to present to Hospital within 120 minutes of Hospital's request for emergency dialysis service."

A review of the facility's policy and procedure (P&P), titled "Hospital Plan for the Provision of Patient Care Services," dated 9/2020, indicated the purpose of the P&P was "the hospital plan for the provision of patient care is the framework for defining the delivery of patient care at [facility]." The P&P also indicated, "Patient care is based on an interdisciplinary assessment of the patient's relevant physical, psychological, social, educational, and environmental status determining the patient's health care needs ... and timely response to changing patient needs ..." The P&P also indicated, "Patient services occur through organized and systemic processes that are designed to ensure safe, effective, timely care and treatment."

Based on interview and record review, the facility failed to develop a restraint care plan per facility policy for 1 (one) of 2 (two) sampled patients (Patient 22). This deficient practice had the potential for lack of intervention and missed patient goals while restraints were ordered and applied for Patient 22.

Findings:

A review of Patient 22's History and Physical (H&P) indicated that Patient 22 was admitted on 4/23/2022 and was brought in for altered level of consciousness. H&P indicated, "he (Patient 22) was more confused than normal ..."

A review of Patient 22's Order Information for: Restraint (something that restricts freedom or prevents someone from doing something) Non-Violent was ordered on 4/23/2022 at 10:23 pm. Restraint order indicated, "Restraint type: Limb holder (soft)", "Restraint Location Non Violent: Bilateral Wrists", and "Reason for Restraint: Alternative Interventions ineffective, Attempts to remove lines or tubes, Agitation/Combative behavior, Inability to comply w/ (with) safety measures."

During a concurrent interview and record review on 6/8/2022, at 10:17 a.m., with Registered Nurse-Nursing Informatics (RNI), Patient 22's Restraint documentation on 4/23/2022 was reviewed. Restraint documentation indicated restraint was applied on 4/23/2022 at 10:00 p.m.

During a concurrent interview and record review on 6/8/2022, at 11:23 a.m., with RNI, Patient 22's IPOC (Interdisciplinary Plan of Care) for Non-Violent Restraints was reviewed. RNI stated, IPOC was initiated on 5/3/2022 4:58 p.m.

During an interview on 6/8/2022, at 11:25 .am., with Clinical Nurse Specialist (CNS), CNS stated, expectation for nurses is to initiate care plans within 24 hours of admission.

A review of the facility's policy and procedure (P&P), titled "Interdisciplinary Plan of Care (IPOC)," effective date 9/2020, indicated a purpose to ensure that "the nursing staff develops, and keeps current, a nursing plan of care for each patient. The nursing plan of care is part of the interdisciplinary plan of care (IPOC)." Policy statement indicated, "A. The interdisciplinary plan of care will be initiated as soon as possible after admission for each patient and operational within 24 hours of patient admission." Policy statement indicated, "D. The IPOC is kept current by ongoing assessments of the patient's needs and the patient's response to goals or outcomes, interventions, and updating or revising the patient's IPOC in response to assessments." Policy procedure indicated, "C. EVALUATION AND REVISION OF IPOC: The goals, expected outcomes and intervention in the plan will be reviewed, revised, and resolved in consultation with the patient/significant other as the patient's condition or diagnosis changes. The plan may be updated every shift and as patient needs indicate."

Based on interview and record review, the facility failed to ensure three (3) of 12 sampled patients (Patients 7, 8, and 17) were reassessed for pain following administration of pain medication.

This deficient practice had the potential to result ineffective pain management for Patients 7, 8, and 17.

Findings:

A review of Patient 7's History and Physical (H&P), dated 6/6/2022, indicated Patient 7 was admitted to the facility on 6/6/2022 for recurrent diverticulitis ( an inflammation or infection in one or more small pouches in the digestive tract).

During a concurrent interview and record review on 6/8/2022, at 9:05 a.m., with the Patient Safety Officer (PSO) and Registered Nurse 6 (RN6), Patient 7's Medication Administration Record (MAR) was reviewed. The MAR indicated that Patient 7 received Norco (pain medication) 5/325 milligrams (mg-a unit of measurement) by mouth as needed for a pain level of 4-6 (on a scale of 0-10 with 0 being no pain and 10 being the worst pain) on 6/6/2022 at 11:57 a.m. The MAR further indicated that pain reassessment was due one hour after the medication was given at 12:57 p.m. RN 6 confirmed that the pain reassessment was not documented on the MAR.

A review of Patient 8's H&P, dated 5/26/2022, indicated Patient 8 was admitted to the facility on 5/26/2022 for constipation, shortness of breath, lower extremity swelling, and abdominal pain.

During a concurrent interview and record review on 6/8/2022, at 9:18 a.m., with the PSO and RN 6, Patient 8's MAR was reviewed. The MAR indicated that Patient 8 received Dilaudid (pain medication) 0.25 mg intravenously (IV - through the veins) as needed for breakthrough pain at 3:32 p.m. The MAR further indicated that pain reassessment was due at 4:02 p.m. RN 6 confirmed that the pain reassessment was not documented on the MAR.

A review of Patient 17's H&P, dated 6/6/2022, indicated Patient 17 was admitted on 6/6/2022 for a scheduled repeat Cesarean section (C-section - surgery to deliver a baby through an incision in the abdomen).

During a concurrent interview and record review on 6/8/2022, at 9:46 a.m., with the PSO and RN 6, Patient 17's MAR was reviewed. The MAR indicated that Patient 17 received Motrin (pain medication) 600 mg by mouth at 4:53 p.m. for a pain level of 5. The MAR further indicated that pain reassessment was due at 5:53 p.m. RN 6 confirmed that the pain reassessment was not documented on the MAR.

A review of the facility's policy & procedure (P&P), titled "Pain Management," effective 5/2019, indicated, "The nurse is prompted by the MAR to reassess the patient. This reassessment occurs in the first hour (approximately) following administration. Onset and duration of the medication(s) are used in the determination of the timing of the reassessment task in the EHR."