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 and record review for 1 of 10 (Patient #1) medical records the medical staff failed to:

1.) Respond promptly and adequately to Patient #1's need for pain control.

2.) Discuss and develop a treatment plan that would effectively control Patient #1's pain.

Findings include:

Surgeon #1's Admitting Orders, dated 9/5/13 at 5:00 P.M. indicated that Morphine 2 milligrams (mg) intravenous (IV) every 30 minutes, when necessary, was ordered to control Patient #1's pain.

The Nursing Note, dated 9/5/13, at 7:52 P.M. indicated Patient #1 was crying in pain and Patient #1 stated that his/her pain relief lasted only 15 minutes at a time.

The Emergency Department (ED) Physician said she ordered Fentanyl for Patient #1 to bring her pain level down. The ED Physician said she did not notify Surgeon #1 that Patient #1 received Fentanyl. The ED Physician said she thought the Morphine ordered for pain management would control Patient #1's pain.

Registered Nurse (RN) #1 was interviewed at 2:30 P.M. on 9/24/13. RN #1 said she called Surgeon #2 (on 9/5/13 at 11:27 P.M.) and Surgeon #2 gave her a telephone order for Patient Controlled Analgesia (PCA) of Morphine.

RN #2 was interviewed at 3:00 P.M. on 9/23/13. RN #2 said Patient #1 reported no pain relief after approximately one hour of the PCA. RN #2 said Surgeon #2 was paged.

RN #3 was interviewed at 7:30 A.M. on 9/24/13. RN #3 said she reported Patient #1's request for Fentanyl to the nursing supervisor and she paged Surgeon #2. However, Surgeon #2 did not call back.

Surgeon #2 was interviewed at 10:25 A.M. on 9/24/13. Surgeon #2 said he does not always remember calls received in the middle of the night.

The Surveyor interviewed RN #4 at 12:25 P.M. on 9/23/13. RN #4 said she was the day nurse, assigned to care for Patient #1, on 9/6/13. RN #4 said that when she first assessed Patient #1, he/she reported severe abdominal pain and reported that the Morphine had not alleviated his/her pain. RN #4 said she reported Patient #1's pain to her Nurse Manager and Surgeon #1.

Physician Orders at 9:00 A.M., dated 9/6/13, indicated Surgeon #1 ordered Patient #1 to be transferred to the Intensive Care Unit so that Fentanyl could be administered to Patient #1 for pain relief.
Based on review of 1 of 10 medical records (Patient #1) and Hospital policy titled Pain Management, the Hospital failed to assure pain assessments were performed according to Hospital policy.

Findings include:

The Hospital policy titled Pain Management indicated that pain is whatever the experiencing person says it is. The Hospital policy indicated all patients undergo reassessment of pain at a minimum of every 8 hours and after every pain intervention. All patients are asked to use a self report pain scale of 0-10 and the pain level will be documented in the patient's medical record.

Emergency Department (ED) Medication Administration Record (MAR), dated 9/5/13, indicated Patient #1 received intravenous (IV) Fentanyl 100 micrograms (mcg) at 7:50 P.M.

The ED Nursing Note, dated 9/5/13, at 7:52 P.M. indicated Patient #1 was more comfortable after the administration of Fentanyl. However, the numerical value was not documented as required.

Patient #1's MAR, dated 9/5/13, indicated at 10:23 P.M. Patient #1 was administered 2 milligrams (mg) of Morphine. There was no re-assessment of Patient #1's pain, documented by RN #1, in Patient #1's medical record.

The Nursing Assessment, dated 9/6/13 at 12:00 A.M. indicated Patient #1 rated his/her pain at 9 out of 10.

The Morphine PCA record, dated 9/6/13 indicated that at 1:15 A.M. Patient #1's PCA began. The Morphine PCA protocol equired that pain and sedation levels be monitored every 2 hours. However, there were no reassessments of Patient #1's pain and sedation level on the Morphine PCA record until 6:00 A.M. The Morphine PCA record indicated that at 6:00 A.M. Patient #1 rated his/her pain at 9 out of 10.
Based on record review and interview it was determined the nursing staff failed to administer Patient Controlled Analgesia (PCA) as ordered to 1 patient (Patient #1) from a sample of 10 records.

Findings include

The PCA Physician Order Sheet, dated 9/8/13, at 11:27 P.M. indicated that 2 milligrams (mg) of Morphine was to be administered at a basal rate (basal rate is the amount of drug given as a continuous infusion and is set per hour. Basal rate is useful in opioid tolerant patients, patients with severe rest pain and for nighttime analgesia) to Patient #1.

The PCA Infusion Flow Sheet, dated 9/8/13, indicated the basal rate of Morphine ordered for Patient #1 was not entered into the pump which administered the infusion of Morphine to Patient #1.

RN #2 was interviewed at 7:30 A.M. on 9/24/13. RN #2 said she was the charge nurse during the night shift on 9/8/13. RN #2 said that she assigned RN #3 to care for Patient #1. RN #3 said that RN #2 reported to her that she did not know how to set up a PCA pump. RN #2 said she set up the pump with RN #3 and reviewed and explained how to monitor Patient #1.

The PCA Infusion Flow Sheet, dated 9/8/13, at 1:15 A.M. indicated that RN #2 co-signed with RN #3 that the Morphine was correctly programmed into the pump.