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DALE MEDICAL CENTER 126 HOSPITAL AVE OZARK, AL 36360 May 26, 2011
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on Alabama Board of Nursing Rules, medical record review, policy review and interview with staff, it was determined the facility failed to reassess 1 of 1 patient after the administration of an as needed pain medication. This affected Patient Identifier (PI) # 4 and had the potential to affect all patients served at this facility.

Findings include:

Alabama Board of Nursing Rule

610-X-6-.07 Medication Administration and Safety

(2) The registered nurse or licensed practical nurse shall exercise decision-making skills when administering medications, to include but not limited to:
(a) If medications should be administered.
(b) Assessment of patient's health status and complaint prior to and after administering medications including as needed (PRN) medications.


Facility Policy
Subject: Assessment and Measurement of Pain


Policy:
Patients shall have individual assessments of his/her level of comfort/pain that includes consideration of the age of the patient, as well as both subjective and objective indicators. Pain levels shall be assessed on admission and at regular intervals, as indicated. Upon identification of pain the patient shall have interventions utilized to assist in coping with and managing the pain experience.


General Information:
Upon noting assessment data indicating that the patient is experiencing pain, the nurse may administer medication as ordered and/or consult the physician (as indicated) for possible utilization of an alternative treatment modality.


Facility Policy
Assessment and Reassessment of the Medical Surgical Patient

Policy:
... The assessment of the care or treatment needs of the patient will be ongoing throughout the patient's hospital stay.

Procedure:
...The scope and intensity of any further assessments are determined by the patient's diagnosis, treatment setting, patient's desire for treatment and patient's response to previous treatment.


1. PI # 4 was admitted to the facility on [DATE] with admitting diagnoses including Probable malignant obstruction splenic flexure of the colon and a history of Urinary Retention.

Review of the Patient Progress Note dates 4/23/11 revealed the Registered Nurse (RN) (Employee Identifier #1) administered Dilaudid 2 milligrams (mg) (prescribed for pain) Intravenous and Zofran 4 mg (prescribed for nausea) Intravenous at 12:29 (pm). There was no documentation of a pain assessment, nor was there documentation the patient was experiencing nausea. There was no documentation the RN reassessed the patient for pain until 14:18 (2:18 pm), which was 1 hour and 49 minutes later.


An interview was conducted on 5/25/11 at 10:50 AM with Employee Identifier (EI) #1, the Registered Nurse as documented above. During this interview, EI # 1 verified a pain assessment was not documented, nor was a reassessment of the patient's pain documented.