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ST ELIZABETH MEDICAL CENTER 2209 GENESEE STREET UTICA, NY 13501 May 12, 2016
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on findings from facility document review, medical record (MR) review and interview, pain management practices were not consistent with generally accepted standards of nursing care. Specifically, (1) the time intervals for pain reassessments after receiving pain medication were excessive (in 4 of 5 MRs reviewed of patients receiving pain medications). Additionally, (2) patients assessed for skin breakdown, using the Braden Scale assessment and scoring tool, lacked documentation of change in patient's position and/or turning and positioning every 2 hours (in 3 of 3 MRs of patients identified as at risk for pressure ulcer development.)

Findings regarding (1) include:

-- Per review of the facility's policy and procedure (P&P) titled "Pain Evaluation," last revised 4/19/16, it indicated when intravenous (IV) opioid pain medication is administered the patient's pain level should be reassessed within 30 minutes. When opioid pain medications are administered by mouth (PO), pain reassessment should occur within 60 minutes.

-- Per review of Patient #1's MR, nursing administered IV opioid pain medication on 2/23/16 at 11:30 am due to a pain level of 8 (pain scale 0-10, with 10 being the most severe.) Reassessment of Patient #1's pain level was not done until 3:00 pm (3.5 hours later) and at that time Patient #1's pain was a level 7. The same lack of pain reassessment after IV opioid pain medication administration occurred on 2/24/16 at 7:15 am, due to a pain level of 7. Reassessment of Patient #1's pain level was not done until 11:00 am (4 hours later.)

-- Per review of Patient #2's MR, nursing administered a PO opioid pain medication on 5/12/16 at 1:06 am, for a pain level of 8. Reassessment of Patient #2's pain level was not done until 4:00 am (3 hours later.)

-- Per review of Patient #3 and Patient #4 MRs, the same lack of timeliness for reassessment of the patient's pain level after receiving pain medication was documented.

-- Per interview of Staff A on 5/12/15 at 9:30 am, he/she acknowledged the above findings.

Findings regarding (2) include:

-- Per review of the facility's P&P titled "Skin Care Policy and Procedure," dated 7/2015, nursing staff should assess a patient's risk for pressure ulcer development using the Braden Scale. For patients identified as at risk for pressure ulcer development (i.e., Braden score <19) nursing staff should document the frequency of turning and positioning and the specific position of the patient. For subscores of 1, 2, or 3 in the Braden subscale areas of sensory perception, activity and mobility, or scores of 1 or 2 for friction and shear, nursing staff should reposition the patient every 2 hours (q2h) or more frequently if there is evidence of pressure on their skin. Repositioning should be documented in the MR.

-- Per review of Patient #5's MR, on 5/11/16 nursing documented a Braden score of 11 (high risk) with an activity sub score of 1 (bedfast.) On 5/11/16 nursing documentation indicated the Patient #5 was turned q2h between 1:00 am and 7:15 am. However, it lacked documentation regarding the specific position of the patient.

-- Per review of Patient #6's MR, on 5/10/16 nursing documented a Braden score of 16 (mild risk) with an activity sub score of 2 (ability to walk severely limited.) On 5/10/16 from 7:30 pm until 5/11/16 at 3:30 am, nursing documentation indicated Patient #6 was turned every 4 hours (not q2h as required by P&P.) Additionally, the MR lacked documentation regarding the specific position of the patient.

-- Per review of Patient #7's MR, on 5/11/16 nursing documented a Braden score of 18 (mild risk) with an activity sub score of 3 (walks occasionally for short distance, most of day spent in bed or chair.) On 5/11/16 from 11:00 am until 5:00 pm, nursing documentation indicated Patient #7 turned independently q2h. However, it lacked documentation regarding the specific position of the patient.

-- Per interview of Staff A on 5/12/16 at 11:00 am, he/she acknowledged the above findings.