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Based on review of 10 medical records and staff interviews it was revealed that the nursing staff failed to effectively manage pain for 1 patient.

Patient #6's post-operative pain was not managed as evidenced by pain scores of 6-8 out of 10 on a numeric pain scale (numeric pain scale ranges from 0-10 with 0 being no pain and 10 being the most pain imaginable to the patient). Patient #6 was ordered Hydromorphone Patient Controlled Analgesia (PCA), an intravenous opioid pain medication in which the patient could push a button and receive a dose of the medication according to the physician's orders, up to six doses per hour. No continuous dose of pain medication was ordered for Patient #6.

The nursing PCA documentation was as follows:

05/09/2015 9:37 AM- pain rating 4, dose given 10, attempted doses 17
05/09/2015 12:21 PM- Pain rating 6, dose given 5, attempted doses 6
05/10/2015 11:30 AM pain rating 5, doses given 4, attempted doses 9
05/10/2015 4:30 PM pain rating 6, doses given 9, attempted doses 21
05/10/2015 8:00 PM pain rating 5, doses given 4, attempted doses 10
05/11/2015 12:53 AM pain rating 4, doses given 10, attempted doses 24
05/11/2015 4:18 AM pain rating 6, doses given 3, attempted doses 7
05/11/2015 7:52 AM pain rating 8, doses given 0, attempted doses 0
05/11/2015 7:45 PM pain rating 8, doses given 3, attempted doses 11
05/11/2015 11:55 PM pain rating 7, doses given 4, attempted doses 27
05/12/2015 5:00 AM- pain rating 7, dose given 1, attempted doses 3
05/12/2015 8:33 AM- pain rating 7, dose given 2, attempted doses 6
05/12/2015 11:50 AM- pain rating 6, doses given 8, attempted doses 24
05/12/2015 12:05 PM- (nursing student note) pain rating 8
05/12/2015 3:58 PM- pain rating 8, dose given 5, attempted doses 9
05/12/2015 8:00 PM-pain rating 6, dose given 7, attempted doses 10
05/13/2015 12:15 AM- pain rating 8, dose given 2, attempted doses 4
05/13/2015 5:20 AM- pain rating 8, dose given 2, attempted doses 4
05/13/2015 8:25 AM- pain rating 8, dose given 6, attempted doses 17
05/13/2015 12:04 PM pain rating 0

An interview with the unit manager on 5/13/15 at 2:10 PM confirmed the documented findings and revealed that patients with ongoing pain scores greater than 6 (moderate to severe pain) may be administered other adjunct medications such as acetaminophen (if ordered) which could potentiate the effects of the Hydromorphone. No nursing documentation was provided to the surveyor to indicate that the physician was notified for further pain management orders even though Patient #6's pain rating was 6 or above for four consecutive days. Documentation indicated that Acetaminophen was administered on 5/13/15 at 12:41 PM. It was noted that the Acetaminophen was not given for pain.

Review of hospital policies revealed a policy entitled "Interdisciplinary Clinical Practice Manual-Patient Care-Pain, Assessment, and Management." This policy outlined procedures for pain assessments for inpatients. In summary the policy stated that in "patients with moderate to severe pain, the physician shall be notified, and pain consultations may be ordered." While Patient #6 experienced moderate to severe pain (pain ratings greater than 6), the physician was not notified and pain consultations were not ordered for four consecutive days.

The hospital's failure to adequately manage patient #6's pain could have potentially led to adverse physical and psychological outcomes for the patient.
Based on review of ten medical records , it was determined that the written or dictated operative report for one patient ( Patient #2 ) was not found in the patient's medical record at the time of the survey.

Per the records , Patient #2 had surgery on 5/13/15. The patient was received in the Post-operative Care Unit (PACU) at 10:42 AM. The patient's medical record was reviewed at 1:15 PM. Neither a written nor a dictated operative report was found in the medical record. Staff informed the surveyor that the operative report was late and not in the medical record at the time of the surveyor's review. The hospital failed to meet the requirements to complete and sign the operative report immediately after surgery.