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CLEVELAND CLINIC MARTIN NORTH HOSPITAL 200 SE HOSPITAL AVE STUART, FL 34995 Dec. 2, 2015
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on record review, policy review and interview, it was determined the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care. This failure affects 1 of 5 sampled patients (Patient # 7) as evidenced by failure to accurately assess pain, failure to reassess pain interventions and failure to follow physician orders for medication administration.

The findings included:

Clinical record review conducted on 12/01/15 revealed the following:

1) Patient # 7 was prescribed Tylenol 500 mg every six hours as needed for pain on 04/17/15. Medication Administration Record (MAR) documents Patient # 7 received the prescribed pain medicine on 04/20/15 at 10:08 PM; 04/21/15 at 10:01 PM; 04/23/15 at 5:09 AM; 04/23/15 at 8:47 PM; 04/24/15 at 9:18 PM; 04/25/15 at 8:34 PM; 04/26/15 at 10:36 PM and 05/02/15 at 4:25 PM.

The record failed to provide evidence of pain assessment and reassessment as per facility policy.

Facility policy titled " Pain Assessment and Management " undated, documents " Pain Management: The use of pharmacological and non-pharmacological interventions to control the patient ' s identified pain. Pain assessment: an evaluation of the cause of the patient ' s pain including but not limited to location, intensity, duration of pain, aggravating and relieving factor, effects on activities and effectiveness of current strategies. The pain reassessment includes the rating from the pain screen.
The RN (Registered Nurse) shall assess the effectiveness of the pharmacologic and non-pharmacologic interventions and document the assessment on the nursing pain reassessment Flowsheet at the following intervals: IV (intravenous) medications: thirty minutes after administration; Oral and intramuscular medications one hour after administration and sixty minutes after administering a non-medication comfort measure".

2) Patient # 7 was prescribed Senna Docusate two tabs twice a day on 04/27/15. Review of the Medication Administration Record revealed Patient # 7 received an incorrect dose (one tab instead of two) on 05/01/15 evening dose and on 05/03/15 morning and evening doses. The record provides no evidence of a physician ' s order for Senna one tablet.

3) Patient # 7 was prescribed Roxicodone 10 mg every six hours as needed for pain on 04/25/15. Medication Administration Record documents on 04/30/15 Patient # 7 received Roxicodone 5 mg instead of 10 mg. The record provides no evidence of a physician ' s order for Roxicodone 5 mg as of 04/30/15.

4) Patient # 7 was prescribed Mycostatin 5 milliliters orally every six hours on 04/26/15. The Medication Administration Record documents Patient # 7 received the prescribed Mycostatin at the wrong time on 04/26/15 at 10:30 PM; 05/02/15 at 2:10 PM and on 05/03/15 at 10 PM,
Facility policy titled " Medication Administration " undated, documents " Timing of Medication Administration: medications will be administered within thirty minutes before and after the scheduled time. Administration times for every six hours, 12 midnight, 6 AM, 12 noon and 6 PM. Medication administration process documents: Review electronic MAR, verify patient identity, scan each medication and verify right patient, right medication, right dose, right time/frequency, and right route " .

Interview with The Risk Manager, who was navigating the electronic record, conducted on 12/01/15 at 3:47 PM confirmed there is no evidence of an accurate pain assessment and pain reassessment prior to and after administering the pain medicine and there is no evidence of physicians ' orders for the discrepancies related to the Roxicodone, Senna and Mycostatin identified above.