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.
| MILTON S HERSHEY MEDICAL CENTER | 500 UNIVERSITY DRIVE HERSHEY, PA 17033 | Sept. 18, 2014 |
| VIOLATION: RN SUPERVISION OF NURSING CARE | Tag No: A0395 | |
| Based on review of facility policy, medical record (MR), and interview with staff (EMP), it was determined the facility failed to evaluate the nursing care, in accordance with their pain assessment policy, for three of four medical records reviewed (MR6, MR7 and MR9). Findings include: A review on September 16, 2014, of "facility policy "Pain Management Inpatient/Ambulatory Care" effective July 2014 revealed, "...Pain interventions will be instituted when a patient reports an unacceptable level of pain, as perceived by the patient. ... Pain is assessed as follows: a. Mild (total score of 1-3) b. Moderate (total score 4-6) c. Severe (total score 7-10) a. The effectiveness of the intervention will be evaluated at 30 minutes for IV administration b. The effectiveness of the intervention will be evaluated at 60 minutes for PO medication and non-pharmacologic interventions. ..." A review on September 16, 2014, of MR6 revealed the patient was administered Oxycodone 10 milligrams (mg) po (by mouth) on September 15, 2014, at 5:16 PM and 11:19 PM. The MR6 failed to contain evidence of an assessment of the pain level and the effectiveness of the intervention. A review on September 16, 2014, of MR8 revealed the patient received Morphine 2 mg IV (intravenous) on September 15, 2014, at 8:19 PM. MR8 failed to contain evidence that the patient was reassessed in 30 minutes. A review on September 16, 2014, of MR9 revealed the patient received Dilaudid 0.4 mg IV on September 15, 2014, at 12 midnight. MR9 failed to contain evidence that the patient was reassessed in 30 minutes. An interview conducted on September 16, 2014, between 11:15 AM through 1:00 PM with EMP2, confirmed the facility did not follow their policy for the assessment of pain level and/or the effectiveness of intervention for MR6, MR8 and MR9. |
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| VIOLATION: ADMINISTRATION OF DRUGS | Tag No: A0405 | |
| Based on review of facility policy, medical record (MR), and interview with staff (EMP), it was determined the facility failed to follow their policy for the assessment of pain for three of four medical records reviewed (MR6, MR7 and MR9). Findings include: A review on September 16, 2014, of "facility policy "Pain Management Inpatient/Ambulatory Care" effective July 2014 revealed, "...Pain interventions will be instituted when a patient reports an unacceptable level of pain, as perceived by the patient. ... Pain is assessed as follows: a. Mild (total score of 1-3) b. Moderate (total score 4-6) c. Severe (total score 7-10) a. The effectiveness of the intervention will be evaluated at 30 minutes for IV administration b. The effectiveness of the intervention will be evaluated at 60 minutes for PO medication and non-pharmacologic interventions. ..." A review on September 16, 2014, of MR6 revealed the patient was administered Oxycodone 10 milligrams (mg) po (by mouth) on September 15, 2014, at 5:16PM and 11:19 PM. The MR6 failed to contain evidence of an assessment of the pain level and the effectiveness of the intervention. A review on September 16, 2014, of MR8 revealed the patient received Morphine 2 mg IV (intravenous) on September 15, 2014, at 8:19 PM. MR8 failed to contain evidence that the patient was reassessed in 30 minutes. A review on September 16, 2014, of MR9 revealed the patient received Dilaudid 0.4 mg IV on September 15, 2014, at 12 midnight. MR9 failed to contain evidence that the patient was reassessed in 30 minutes. An interview conducted on September 16, 2014, between 11:15 AM through 1:00 PM with EMP2, confirmed the facility did not follow their policy for the assessment of pain level and/or the effectiveness of intervention for MR6, MR8 and MR9. |
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