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.

TWIN RIVERS REGIONAL MEDICAL CENTER 1301 FIRST ST KENNETT, MO 63857 May 31, 2012
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and policy/record review the facility failed to ensure staffing was in adequate numbers and/or assigned appropriately in order to meet the needs of five (#8, #9, #11, #12, and #10) of seven patients reviewed. This had the potential to affect all patients. The facility census was 27.

Findings included:

1. Review of the facility policy titled, "Nurse Staffing Plan," dated 06/30/09, showed the following direction:
-The staffing plan is based on the expected nursing care required by the unit population;
-Factors taken into consideration when adjusting the staffing plan include census, intensity of care required, skill and experience of staff, and admissions and discharges.

2. During an interview on 05/30/12 at 8:40 AM Patient #8 stated the following:
-Patient #8 complained of pain at a rating of "8," on a scale from one-ten with 10 being the worse pain. The patient stated that she had been admitted through the emergency department (ED) in excruciating pain related to colon problems and Fibromyalgia (a chronic muscle pain); however, she was not given pain medication for approximately five hours, even though requested. Patient #8 stated that the nurses told her the delay in providing medication was related to being busy with multiple patient admissions and discharges.

Review of the patient's physician's orders dated 05/29/12, showed an order for Hydrocodone (an opioid derivative) 10/325 every four to six hours for pain.

Review of the patient's medication administration record (MAR) showed the following:

-Hydrocodone was administered on 05/29/12 at 11:31 PM for a pain rating of "7".

3. Review of Patient #11's History and Physical (H & P) dated 05/29/12 showed the patient was admitted on [DATE] as a direct admission from the physician's office with diagnoses of [DIAGNOSES REDACTED]

During an interview on 05/30/12 at 10:31 AM, Patient #11's (a minor) mother stated that they came to the hospital at about 3:45-4:45 PM on 05/29/12 and arrived on the 3 South unit at about 5:00 PM. After being in the room about two and one-half hours, she had to go to the nurses' station to find out which bed (two beds per room) the patient would be assigned so they could get settled. The patient had not been provided any care up to this point. The patient's mother complained to the manager. When the night shift nurse came in later at 7:30 PM, an intravenous (IV) line was started; breathing treatments and medications were administered. The patient's mother stated no physical assessment had not been completed as of this interview. The patient's mother had to ask for diapers, wipes and milk for Patient #11's bottle, and waited seven hours for those. Facility staff failed to assess and provide care based on that assessment in a timely manner.

4. During an interview on 05/30/12 at 3:02 PM, Staff N, Registered Nurse (RN), stated that the rehabilitation unit (Rehab) was staffed solely dependent on the unit census, utilizing a staffing matrix (pre-printed). Facility staff failed to staff based on acuity of patients.

5. During an interview on 05/30/11 at 3:50 PM, Staff GG, Licensed Practical Nurse (LPN) stated that she was unable to provide medication ordered on [DATE] for Geodon (antipsychotic) 20 milligrams (mg), by mouth (PO), twice a day (BID) and Paxil (antidepressant) 20 mg, PO every morning (AM), give first dose (of both medications) this AM. She was unable to administer the medications ordered to Patient #12 until 12:11 PM, because she had assisted with another agitated patient.

6. During an interview on 05/31/12 at 8:35 AM, Staff SS, RN, stated the wound clinic was staffed solely dependent on the unit census, utilizing a staffing matrix. And, the staffing matrix was strictly adhered to. The typical number patients seen in a day was 12-20, for various wound needs from wound vac treatment, to diabetic/pressure sore care, and hyperbaric treatments (an oxygen enriched environment which promotes healing).

7. During an interview on 05/30/12 at 8:47 AM, RN Staff Z stated there was a current census of 18, with a capacity of 28, on the 3 South unit. Staff Z stated there were five nurses on 3 South on 05/29 and 05/30/12.

Review of the 3 South staffing matrix showed licensed staff allowed for a census of 18 was five for the 7:00 AM to 7:00 PM shift. For 28 patients, they allowed eight licensed staff.

During an interview on 05/31/12 at 9:35 AM, Physician NN stated there were not enough nurses to provide quality care on the 3 South unit. Physician NN stated he would admit his patients to the intensive care unit (ICU) if at all possible so that they would receive better, or more reliable care. Physician NN stated he felt some of the staffing issues may be related to poor mentoring, numbers of staff, or poorly organized staff based on their experience. Physician NN stated there were quite a few nurses that had resigned recently.

8. Review of Patient #9's H & P, dated 05/28/12 showed the patient was admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]

Review of the patient's physician's orders dated 05/29/12 showed orders for Tylenol every 4-6 hours for pain, or Percocet (pain medication) one to two tablets four times daily.

During an interview on 05/31/12 at 9:40 AM, Patient #9 stated he had leg pain and needed something for the pain. Patient #9 had previously asked the nurse for something, but had not received it.

LPN Staff PP stated the patient had asked for a pain medication approximately 45 minutes earlier; however, he had been unable to provide any ordered pain medication to Patient #9 because there had been another patient that required a medical test, utilizing the nurse's time. Staff failed to provide pain medication in a timely manner, even though requested.

9. Review of Patient #10's anesthesia history dated 05/29/12, showed he was admitted to the 3 South unit on that date for a left shoulder manipulation and removal of old hardware (screws). The patient had a history of diabetes, and chronic obstructive pulmonary disease (lung/breathing problems). The patient provided a list of home medications to the facility prior to the surgery, including Pulmocort and Ventolin (breathing medications), and Lantus (insulin) (several home medications taken daily, and if missed could cause health problems) . The patient had this procedure completed on an outpatient basis; however, he was admitted to outpatient observation at 11:00 AM for pain control with the following physician's orders:

-Toradol 30 milligrams (mg) intravenous (IV) every six hours for pain;
-Hydrocodone 10/325 mg every four hours as needed for pain;
-Morphine 5 mg IV every hour as needed for pain;
-Albuterol four times daily and Pulmicort three times daily via nebulizer (a machine that provides inhaled breathing medication) treatments;
-Lantus insulin 52 units at bedtime;
-IV Morphine via a patient controlled analgesia pump;
-Humulin insulin based on a sliding scale (based on blood sugar check).

Review of the patient's physician's orders dated 05/29-30/12 showed staff failed to order all of the patient's home medications until 9:30 AM on 05/30/12. The patient was admitted on [DATE] at 2:20 PM.

During an interview on 05/30/12 at 8:55 AM, the patient's spouse stated the following:
-On 05/29/12, late the day of the surgical procedure, the patient did not get his blood sugar checked, got no insulin, and no home medications were administered;
-It was eight hours before any staff member checked on the patient after admitted to the 3 South unit;
-The patient waited two to three hours for pain medication;
-The attitude of staff was they were too busy to care for the patient;
-They waited four hours for IV fluids to be replaced, after empty. The IV machine beeped, staff came in and shut it off and left;
-Nebulizer treatments were not provided until late the first night, and the patient was in need of them.

Review of the patient's MARs from 05/29/12 at 7:00 AM through 05/31/12 at 7:00 AM, and an overview of medications administered from admission through end of survey showed the following:

-Staff failed to get an order for blood sugar checks;
-Staff failed to administer the Ventolin and/or Pulmocort until 4:12 PM, or twelve hours since last home dose.

Review of nursing terminations since 12/01/11 showed that 24 nursing employees had been terminated and/or resigned in this time period. Sixteen of these positions were full-time. Two of the positions were management in nature.

Review of nursing vacancies as of 05/31/12 showed the following:
-One house supervisor;
-Medical/Surgical (3 South): two certified nurse assistants (CNA), and three RN's;
-Rehab: one CNA, one LPN, and one RN;
-ICU: one RN;
Obstetric/labor and delivery: three RN's;
ED: two RN's;
Clinics: one RN practitioner, and two LPN's.

10. During an interview on 05/31/12 at 11:00 AM Staff A, Chief Nursing Officer, stated that staffing was assigned by the night nurse for the day shift. She stated that assignments were not based on acuity but by the number of patients a nurse would be taking care of. She stated that if there were admissions during a shift, the nurse with the least patients would get the next admission.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and policy/record review the facility failed to ensure the crash carts were checked per policy and supplies were ready for a patient emergency in two of four crash carts checked. The facility also failed to assess one patient timely (Patient #11), failed to administer pain medications to two of five patients (Patients #8 and #9) reviewed with pain in a timely manner, failed to complete the hourly rounding per facility policy on one of two patients reviewed (Patient #10), and failed to keep a medication refrigerator and plastic container for insulin clean and frost-free. The facility census was 27.
A395 Crash Cart Twin Rivers Regional Medical Center

Findings included:

1. Record review of the facility policy titled, "Cardiopulmonary Resuscitation (an emergency procedure in which the heart and lungs are made to work manually) ," dated 08/88 showed:
-The charge nurse of each unit or his/her licensed appointee will do defibrillator (an electric device designed to send an electric shock to the heart to restore a normal heat beat) testing daily.
-By signing the Crash Cart Check Sheet the licensed staff were attesting to the fact that the defibrillator was discharged .
- Crash cart integrity is checked daily by licensed staff. The lock numbers should be recorded on the Crash Cart Check Sheet.
- Nursing personnel will check locks on the crash cart daily and initial the crash cart check sheet in the appropriate space.
-The Cardiopulmonary (relating to the heart and lungs) Department will restock their drawer and deliver the cart to Central Supply for restocking.
-The Cardiopulmonary Department is responsible for the integrity of the third and fifth drawer contents and will check batteries and bulbs.

2. During an interview on 05/30/12 at 9:30 AM in the Obstetrics (OB, labor, and newborn nursery) Department Staff F, RN stated that she had checked the OB crash cart that morning and she only checked the security tag numbers and documented them. That is what she did to check the crash cart each day she was to check it.

3. During an interview on 05/30/12 at 9:35 AM in the OB Department Staff D, Director of OB stated that she was unaware that the defibrillator needed to be checked on the crash cart. She felt it was an oversight due to lack of her education on how to check the crash carts.

4. Observation at the time of the record review of the facility document titled, "Crash Cart Check Sheet," on 05/30/12 at 9:45 AM in the OB Department showed:
-The security tag on drawer #2 was # 06 and the number documented on the "Crash Cart Check Sheet," was # 29.
-The security tag on drawer #3 was # 563 and the number documented on the "Crash Cart Check Sheet," was # 18.
-The security tag on drawer #4 was # 03 and the number documented on the "Crash Cart Check Sheet," was # 92.
-The security tag on drawer #5 was # 71 and the number documented on the "Crash Cart Check Sheet," was # 09.
The numbers need to match to ensure that the cart drawer has not been opened when not needed and that all the supplies needed for a patient medical emergency are in the cart.

Observation at the time of the interview on 05/30/12 at 10:00 AM in the OB department showed:
-The batteries did not work in the base/handle of the laryngoscope (a flexible, lighted tube used to examine the inside of the larynx, voice box) in drawer #3.
- The batteries were removed by Staff D, new batteries were put in, and the light on the laryngoscope came on.
-Staff D removed the new batteries and put the old batteries back into the base/handle of the laryngoscope, but placed them back in differently. The old batteries then worked when correctly placed.
-Staff D stated that Cardiopulmonary Department is responsible for this drawer.

5. Observation at the time of the interview on 05/30/12 at 10:25 AM in the newborn nursery showed that the laryngoscope base/handle was not in the newborn nursery crash cart. Staff D stated that it should have been there.

During an interview on 05/30/12 at 1:51 PM Staff EE, Director of Cardiopulmonary stated that the Cardiopulmonary Department was responsible for the third drawer of the crash cart and the batteries in the laryngoscope base/handle should have been checked before going back to the OB Department. Their department was not responsible for the newborn crash cart.

During an interview on 05/30/12 at 4:10 PM Staff D, stated that the newborn nursery crash cart was the responsibility of the staff in OB with the exception of medications that pharmacy took care of. The base/handle of the laryngoscope must have been used and not replaced. There is not a list of the supplies that should be in the newborn nursery crash cart.

6. Observation and concurrent interview on 05/29/12 at 4:11 PM, showed a crash cart on the 3 South, Medical/Surgical unit, and the following:
-The suction machine, on top of the crash cart, did not have tubing attached;
-Licensed Practical Nurse (LPN), Staff X, had to search for an extended period of time (three to five minutes) for the suction machine tubing in order to make it function properly (patient choking or asphyxiation could lead to death);
-The 3 South manager, Staff Z, stated that the tubing should have been left on top of the cart, or actually attached to the suction machine, for quicker access in case of emergency;
-Staff Z did not know what the facility policy was regarding this and did not answer when asked how they would respond to a suction emergency in the hallway.

7. Observation and concurrent interview on 05/29/12 at 4:40 PM, showed a plastic, divided box with a lid in the medication refrigeration, in the medication room. This plastic box contained nine vials of insulin, some of which were opened. The plastic box was dirty with smudges, and debris. The medication refrigerator freezer had about four inches of ice/frost layered from the top of the freezer. Staff Z stated it was a nursing responsibility to clean the refrigerator and plastic box.

8. During an interview with Patient #8 on 05/30/12 at 8:40 AM showed the following:
-Patient #8 complained of pain at a rating of "8," on a scale from one-ten with 10 being the worse pain. The patient stated she had been admitted through the emergency department (ED) in excruciating pain related to colon problems and Fibromyalgia (a chronic muscle pain); however, she was not given pain medication for approximately five hours, even though requested. Patient #8 stated the nurses told her the delay in providing medication was related to being busy with multiple patient admissions and discharges.

Review of the patient's physician's orders dated 05/29/12, showed an order for Hydrocodone (an opioid derivative) 10/325 every four to six hours for pain.

Review of the patient's medication administration record (MAR) showed the following:

-Hydrocodone was administered on 05/29/12 at 11:31 PM for a pain rating of "7".

Review of a facility policy titled, "Assessment/Reassessment,"dated 02/03, showed the following:
- Assessing the status and identifying the needs of the patient are basis for determining the care to be provided;
- Assessment information includes health history, physical, functional and psychosocial status, and nutritional needs.
- The infants/children assessment process is highly individualized and included development age, and family's expectations.

9. Review of Patient #11's History and Physical (H & P), dated 05/29/12 showed the patient was admitted on [DATE] as a direct admission from the physician's office with diagnoses of [DIAGNOSES REDACTED]

During an interview on 05/30/12 at 10:31 AM, Patient #11's (a minor) mother stated they came to the hospital at about 3:45-4:45 PM on 05/29/12, and arrived on the 3 South unit at about 5:00 PM. After being in the room about two and one-half hours, she had to go to the nurses' station to find out which bed (two beds per room) the patient would be assigned so they could get settled. The patient had not been provided any care up this point. The patient's mother complained to the manager. When the night shift nurse came in later at 7:30 PM, an intravenous (IV) line was started; breathing treatments and medications were administered. However, no physical assessment was completed or documented as of this interview. The patient's mother had to ask for diapers, wipes and milk for Patient #11's bottle, and waited seven hours for those. Facility staff failed to assess and provide care based on that assessment in a timely manner.

Review of a facility policy titled, "Timely Medication Administration," undated, showed the following:
-All medications will be administered in a timely manner according to current medication management standards;
-Scheduled opioids used for chronic pain or palliative care are considered time critical and take priority.

10. Review of Patient #9's H & P, dated 05/28/12 showed the patient was admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]

Review of the patient's physician's orders dated 05/29/12 showed orders for Tylenol every 4-6 hours for pain, or Percocet (an opioid derivative pain medication) one to two tablets four times daily.

During an interview on 05/31/12 at 9:40 AM, Patient #9 stated he had leg pain and needed something for the pain. Patient #9 had previously asked the nurse for something, but had not received it.

LPN Staff PP stated the patient had asked for a pain medication approximately 45-minutes earlier; however, he had been unable to provide any ordered pain medication to Patient #9 because there had been another patient that required a medical test, utilizing the nurse's time. Staff failed to provide pain medication in a timely manner, even though requested.

11. Review of a facility policy titled, "Hourly Rounding, dated 04/09 showed the following:
-All staff will check the four P's (pain, position, potty, and perimeter) prior to leaving the room;
-Nursing staff will make hourly rounds on all patients to ensure that their needs are met;
-Initial rounding sheet to confirm that rounding has been completed.

Review of the Hourly Rounding form for Patient #10, on 05/30/12 at 10:20 AM, showed the documentation of hourly rounding blank since its' initiation at 7:00 AM.

During a concurrent interview, RN Staff S stated the hourly rounding form is to be completed hourly with any patient contact, by any staff member. Staff failed to follow their own policy regarding hourly rounding.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to develop and/or implement an individualized, comprehensive care plan for two (Patients #8 and #14) of 10 patients reviewed with care plans. The facility census was 27.

Findings included:

1. Review of a facility policy titled, "Interdisciplinary Plan of Care," dated 03/03 showed the following:
-The plan for care is a dynamic process that addresses the patient's needs, strengths, and limitations and goals;
-The plan for care should be reviewed regularly and revised;
-Evaluate the plan for care effectiveness;
-The plan for care should include services that optimize comfort.

2. During an interview on 05/30/12 at 9:15 AM, the Chief Nursing Officer, Registered Nurse (RN) Staff A stated it was the responsibility of the nurse admitting the patient to develop the care plan. Then, each nurse should review and update as appropriate.

3. Review of Patient #8's nursing admission assessment dated [DATE], showed she was admitted that date with a diagnosis of gastrointestinal bleed. The patient had a history of arthritis.

During an interview with Patient #8 on 05/30/12 at 8:40 AM showed the following:
-Patient #8 complained of pain at a rating of "8," on a scale from one-ten with 10 being the worse pain. The patient stated she had been admitted through the emergency department (ED) in excruciating pain related to colon problems and Fibromyalgia (a chronic muscle pain).

Review of the patient's Interdisciplinary Plan of Care (IPOC) dated 05/29/12, showed the staff failed to address Patient #8's pain.

4. Review of Patient #14's History and Physical dated 05/27/12, showed the patient was admitted on [DATE] with a diagnosis of accidental pain pill overdose related to chronic back pain.

Review of the patient's nursing admission assessment dated [DATE], showed the patient had pain at a rating of "8," on a scale of one to ten, with ten being the worse pain.

Review of the patient's physician's orders showed an order for a pain medication called Ultram.

Review of the patient's IPOC dated 05/28/12, showed a goal of pain control at a level of "5," or below by discharge.

However, review of the patient's medication administration records and a Physical Therapy notes showed the patient received pain medications for pain ratings of the following:

-On 05/26/12 at 9:45 AM, pain rating of "8";
-On 05/26/12 at 7:50 PM, pain rating of "9";
-On 05/28/12 at 7:28 AM, pain rating of "9";
-On 05/28/12 at 8:37 AM, pain rating of "8";
-On 05/28/12 at 6:18 PM, pain rating of "8";
-On 05/30/12 at 10:25 AM, pain rating of "8".

Even though the patient had consistent pain ratings above "5" and the care plan stated the patient would not experience this level of pain, staff failed to review the goal and amend it, or attempt other interventions to alleviate the patient's pain.

During an interview on 05/30/12 at 3:22 PM, RN Staff S agreed the care plan could have been reviewed and changes made to decrease the patient's level of pain.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and policy/record review the facility failed to ensure medication was given as ordered and to notify the physician to ensure medication was given timely in six (#8, #9, #10, #12, #13, and #15) of nine patient records reviewed. The facility census was 27.

Findings included:

1. Record review of the facility policy titled, "Medication Administration Policy," dated 05/03 showed:
-Medication shall be prepared and administered in accordance with the orders of the prescriber or practitioner responsible for the patient's care and accepted standards of practice.
-Scheduled administration should be within 30 minutes of the time ordered to ensure that therapeutic blood levels are maintained. Stat and preoperative medications should be given at the specific times ordered.
-Medication errors include the wrong time.

Review of the facility policy titled, "Timely Medication Administration," undated, showed the following:
-All medications will be administered in a timely manner according to current medication management standards;
-Time critical medications include scheduled opioids and should not be delayed more than 30 minutes or it may result in sub-optimal effect or cause harm;
-Scheduled opioids used for chronic pain or palliative care are considered time critical and take priority.

Record review of the facility policy titled, "Patient Safescan Solutions," dated 03/08 showed:
-Physician medication orders are processed per usual processes from the nursing unit to the pharmacy and into the clinical pharmacy system.
-Active medication orders are sent to the Safescan System (computer program for medication order input) through an interface to the clinical pharmacy system.
-Nurses have the ability to continue with a medication administration when a warning is displayed by selecting an override reason why the medication dose will be given.

2. During an interview on 05/30/12 at 3:00 PM at the time of the medication record review of Patient #13 showed on 05/27/12:
-At 8:00 AM Risperdal (an antipsychotic medication) 2 milligrams (mg) by mouth (PO) twice a day (BID) was ordered and not started until 9:06 PM. The physician had not been notified to see when he/she wanted the medication started.
-At 11:50 PM Risperdal 3 mg PO every hour of sleep (HS) give first dose now was ordered. The now dose was given at 12:44 AM. This was 54 minutes after the time of the order.
-Staff FF, Nurse Manager of Psychiatric Services stated that this physician that wrote the Risperdal BID order will keep all the patient charts with the new orders until he has completed all of them. By the time the nurses receive the new orders, it can be a lot later than the ordered time. So BID medication will just be started at the next medication time. There was not any documentation of the nurse notifying the physician to see if the medication should be started sooner. A now order should have been given sooner. A patient's behavior would have been the reason for the now order.

During an interview on 05/31/12 at 9:25 AM Staff KK, Regional Pharmacy Manager stated that there was not a policy that defined what the time frame for a now order was.

3. During an interview on 05/30/12 at 3:15 PM Staff HH, Physician stated that he expected when he ordered a BID medication that the nurse would notify him for an order to start the medication late and find out when to give the evening dose.

4. During an interview on 05/30/12 at 3:22 PM Staff GG, Licensed Practical Nurse (LPN) stated that if she takes an order for a BID medication she will just give the first dose late and does not notify the physician for an order.

5. Review of Patient #8's nursing admission assessment dated [DATE], showed she was admitted that date with a diagnosis of gastrointestinal bleed. The patient had a history of arthritis.

Review of physician's orders dated 05/29/12, showed an order for Hydrocodone (an opioid derivative pain medication) 10/325 milligrams (mg) every four to six hours for pain.

During an interview with Patient #8 on 05/30/12 at 8:40 AM showed the following:
-Patient #8 complained of pain at a rating of "8," on a scale from one-ten with 10 being the worst pain. The patient stated she had been admitted through the emergency department (ED) in excruciating pain related to colon problems and Fibromyalgia (a chronic muscle pain); however, she was not given pain medication for approximately five hours, even though requested. Staff failed to administer a time critical pain medication in a timely manner.

Review of the patient's physician's orders dated 05/29/12, showed an order for Hydrocodone (an opioid derivative) 10/325 every four to six hours for pain.

Review of the patient's medication administration record (MAR) showed the following:

-Hydrocodone was administered on 05/29/12 at 11:31 PM for a pain rating of "7".

6. Review of Patient #9's H & P, dated 05/28/12 showed the patient was admitted on [DATE] with a diagnosis of unstable angina (heart pain).

Review of the physician's orders dated 05/29/12 showed orders for Tylenol every 4-6 hours for pain, or Percocet (an opioid derivative pain medication) one to two tablets four times daily.

During an interview on 05/31/12 at 9:40 AM, Patient #9 stated he had leg pain and needed something for the pain. Patient #9 had previously asked the nurse for something, but had not received it. LPN Staff PP stated the patient had asked for a pain medication approximately 45-minutes earlier; however, he had been unable to provide any ordered pain medication to Patient #9 because there had been another patient that required a medical test, utilizing the nurse's time. Staff failed to provide a time critical pain medication in a timely manner, even though requested.

7. Review of Patient #15's Admission Data Form, dated 05/30/12 showed the following:
-Patient #15 was admitted at 1:50 AM, via the ED, on 05/30/12 with a diagnosis of acute depression;
-The patient was confused at admission.

Review of the patient's home medications (several taken daily, and if missed could cause health problems) included the following:
-Premarin 1.25 mg daily (hormone);
-Ranitidine 30 mg twice daily (for heartburn);
-Tramadol 50 mg one or two every six hours for pain;
-Naproxen 500 mg twice daily (anti-inflammatory);
-Metoprolol 25 mg daily (for high blood pressure);
-Hydrocodone (no dose shown) twice daily (for back pain).

During an interview on 05/30/12 at 2:25 PM, RN Staff S, stated the physician of record for this patient had not clarified the admission medications as of this date/time. Staff S confirmed the night shift nurse should have called the physician to get clarification of the orders prior to leaving the shift; however, the nurse failed to do this.

During an interview on 05/30/12 at 2:30 PM, the patient stated she had not received any medications since admission. The patient stated she was now experiencing back pain, rated at a "5," having heartburn, and was fairly anxious.

During an interview on 05/30/12 at 2:43 PM, RN Staff II, stated she had called the physician at 7:40 AM and the physician did not want to verify/order the medications at that time, but would when he/she came to the hospital this afternoon/evening. Staff/physicians failed to administer get medications ordered and administered in a timely fashion.

8. Review of Patient #10's anesthesia history dated 05/29/12, showed he was admitted on that date for a left shoulder manipulation and removal of old hardware (screws). The patient had a history of diabetes, and chronic obstructive pulmonary disease (lung/breathing problems). The patient was to have this procedure completed on an outpatient basis; however, he was admitted to the 3 South unit for pain control.

Review of the patient's physician's orders showed Hydrocodone 10/500 mg four times daily, and morphine 30 mg IV (both opioid, and time critical) was ordered on admission.

During an interview on 05/30/12 at 8:55 AM, the patient had the patient's spouse stated the following:
-On 05/29/12, after the surgical procedure, the patient did not get his home meds administered;
-The patient had waited two to three hours for pain medication, when requested.

Facility staff failed to control this patient's pain, even though that was what he was admitted for.