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.


Based on interview, clinical record review and review of the facility's policies and procedures; the facility failed to ensure timely documentation of reassessment of response to intervention for 1 of 10 patient (Patient #1) records reviewed.

The findings include:

Patient #1 was admitted on [DATE] with admitting diagnoses that include [DIAGNOSES REDACTED]. The telemetry floor provides 24/7 cardiac monitoring of patients by a certified technician.

Review of the clinical record of Patient #1 reveals pain assessments done by the registered nurses on each shift. There is no documentation of pain or orders for pain medication for Patient #1 from admission to the telemetry floor through 01/25/2013 at 1:30 PM. Pain assessment on 01/25/2013 at Noon indicates 0 pain level. Nurse's notes on 01/25/2013 document the registered nurse called the physician (medical and cardiology) to inform them of Patient #1 complaint of pain, between shoulder blades at approximately 1:30 PM. Vital sign assessment was completed at this time and vitals were documented as stable, cardiac rhythm normal. Physician orders were obtained for the administration of pain medication (Morphine 2 mg IV) from cardiology at approximately 1:30 PM. The morphine (opioid) was administered as ordered by the registered nurse at approximately 1:33 PM. There is no further documentation in the clinical record of reassessment of response to the pain medication administration for Patient #1 until approximately 3:00 PM.

Review of the facilities policy and procedure, "Pain Management Protocol" most recently reviewed and revised 07/24/2012 reveals the following information:
"~Etiology of the pain should be determined whenever possible
~Reassessment of pain will be completed within one hour
~More frequent re-assessments are based on individual patient need.
~After administering any opioid medication for pain management, the post opioid pain intensity re-assessment should be performed and documented and the patient should be assessed for signs and symptoms of [DIAGNOSES REDACTED]
~After administration of an opioid assess for signs and symptoms of [DIAGNOSES REDACTED]
~Pain assessment and reassessments as well as intensity scores and pain goals should be documented in the appropriate area of the medical record."

An interview was conducted on 02/12/2013 at 11:00 AM with the registered nurse (RN #2) who administered the morphine to Patient #1 on 01/15/2013 at approximately 1:33 PM. The RN stated,"I was in the room at least twice during that time period and there was also another registered nurse rounding who was in the room, I was aware that she did not receive relief and that is why I placed a call to the physician around 3:00 PM to inform him. During this time she was on a cardiac monitor and her cardiac rhythm was stable. I did not document on the clinical record regarding her condition until after I spoke to the physician again at 3:00 PM "

An interview was conducted on 02/12/2013 at 1:45 PM with the facility risk manger (RN) , Chief nursing Officer (CNO) and unit manager RN (telemetry floor). The unit manager , RN, confirmed the policy and the expectation that any patient administered pain medication should be reassessed for response to the intervention within the hour or less. The CNO and risk manager conferred.