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SOUTHCOAST HOSPITALS GROUP 363 HIGHLAND AVENUE FALL RIVER, MA 02720 Sept. 24, 2013
VIOLATION: MEDICAL STAFF ACCOUNTABILITY Tag No: A0347
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.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
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.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
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.