The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ADVENTHEALTH ORLANDO 601 E ROLLINS ST ORLANDO, FL 32803 Feb. 11, 2016
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on interview, record review and a review of facility documentation, the hospital failed to ensure that pain medications were given in accordance with approved policies which required pain re-evaluations after medication administration for 1 of 10 sampled patients (#1).

Findings:

Patient #1's medical record reflected she was triaged in the emergency room (ER) on 12/27/15 at 1:39 AM. The nursing initial assessment note of 12/27/15 at 2:38 AM read, "Chief complaint detail: cough....Pain eval: pain level: 10. Description: sharp: Location: mid. Pain site: chest." The discharge order was entered at 4:45 AM. Physician orders of 4:45 AM on 12/27/15 read, "Ibuprofen 600 MG (milligrams) Tab PO (by mouth), once, routine." The patient was given Ibuprofen 600 MG one tablet by mouth at 5:02 AM. Pain was assessed at a "10" at the same time (on a scale of 1-10, with 10 being the worst). There were no further pain assessments or pain evaluations after this one.

A review of hospital's policy "Pain Management - Adult" read, "In the ED (Emergency Department), the patient's pain assessment and pain relief shall be evaluated in conjunction with the patient's individual clinical presentation. A pain management plan of care will be established based on the patient's clinical presentation and individual comfort." Thus, the administration of a medication, which brings pain relief, requires a subsequent evaluation of any pain relief.

There was no evidence that an evaluation of pain relief, as stated in this policy, was performed after the 5:02 AM administration. The policy was not followed.

A nurse's note of 12/27/15 at 5:15 AM read, "Discharge disposition: Home.... Discharge transportation: ambulatory." The patient was discharged home without another evaluation after pain medication was given.

During an interview of the Risk Manager at approximately 3:30 PM on 2/11/16, she confirmed the findings.