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.

SAINT THOMAS MIDTOWN HOSPITAL 2000 CHURCH ST NASHVILLE, TN 37236 July 25, 2013
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, facility policy review, and interview, the facility failed to assess a patient; failed to provide adequate pain management; failed to notify physician of unrelieved pain (#15) of seventeen patients reviewed.

The findings included:

Patient #15 was admitted to the facility on on July 11, 2012, with complaints of chronic low back pain, for elective surgery including L5-S1 (5th lumbar vertebra to 1st sacral vertebra) bilateral foraminotomy with pedicle screw fixation and posterolateral fusion. Medical record review revealed the patient had a history of [DIAGNOSES REDACTED], Depression, and Bipolar Disorder.

Medical record review revealed the patient underwent surgery on July 11, 2012, for "...L4-S1 pedicle screw fixation; L5 hemilaminectomy, facetectomy, and foraminotomy. Continued medical record review revealed the patient was discharged home on July 13, 2012, at 11:39 a.m.

Medical record review of physician's orders dated July 11, 2013, at 6:30 p.m., revealed orders for Percocet (pain medication) 10 milligrams (mg) orally every 4 hours as needed; Morphine sulfate 1-6 mg intravenously (IV) every hour as needed; Fentanyl (narcotic pain medication) 25 micrograms (mcg) every 5 minutes to maximum of 100 mcg while in Recovery Room; Toradol (pain medication) 30 mg IV every 6 hours up to 12 doses.

Medical record review of medication administered in the Recovery Room revealed the patient received Morphine Sulfate 2 mg IV ten times; Fentanyl 25 mcg IV 4 times; Toradol 30 mg IV once; and Percocet 10 mg orally once.

Medical record review of physician's orders dated July 11, 2012, at 10:10 p.m., revealed an order to discontinue the Morphine Sulfate and start a Patient Controlled Analgesia (continuous dose delivered as well as patient pushing button to receive extra doses) of Dilaudid (narcotic analgesic) according to the protocol.

Medical record review of the Medication Administration Record (MAR) dated July 12, 2013, revealed the patient received Percocet 10 mg orally at 12:31 a.m. for a pain level of 7/10 (10 being the worst), and Toradol 30 mg IV at 1:42 a.m. for a pain level of 9/10.

Medical record review of physician's orders dated July 12, 2012, at 2:35 a.m., revealed an order for "...Valium 10 mg now and three times daily (TID) for agitation/spasms..."

Medical record review of the MAR dated July 12, 2012, revealed the patient received Percocet 10 mg orally and Valium 10 mg orally at 4:35 a.m., for a pain level of 8/10. Continued medical record review revealed the patient's pain level one hour later was 9/10.

Medical record review of physician's orders dated July 12, 2012, at 7:30 a.m., revealed orders to discontinue the Dilaudid, Percocet, and Valium; start Oxycontin (long-acting narcotic analgesic) 60 mg twice daily (BID); and Oxycodone (short acting narcotic analgesic) 30 mg every 4 hours as needed.

Medical record review of the MAR dated July 12, 2012, revealed at 7:58 a.m., the patient received Toradol 30 mg and Xanax 1 mg for a pain level of 10; at 8:46 a.m., the patient received Oxycodone 30 mg for a pain level of 10/10; and at 8:58 a.m., the patient received Toradol 30 mg for pain level of 7/10. Continued review of the MAR revealed the patient responded "no" to the question of 'patient satisfied with pain control'. Continued review of the medical record revealed no documentation the physician was notified of the patient's pain level and dissatisfaction with pain control.

Review of the MAR dated July 12, 2012, revealed at 11:18 the patient received the scheduled Oxycontin 60 mg and pain level was 7/10. Further review of the MAR dated July 12, 2013, revealed at 1:48 p.m., the patient received Xanax 1 mg; and at 2:47 p.m. the patient received Oxycodone 30 mg for a pain level of 8/10 which decreased to a level of 3/10 an hour later. Further review of the MAR dated July 12, 2012, revealed the patient received Oxycodone 30 mg at 7:47 p.m. for a pain level of 10/10, which was 8/10 an hour later, and documented as the patient being satisfied with pain control. Continued review of the MAR dated July 12, 2012, revealed the patient received the scheduled Oxycontin 30 mg and Xanax 1 mg at 10:30 p.m., for a pain level of 10/10 which had decreased to 7/10 an hour later.

Review of the MAR dated July 13, 2012, revealed at 4:27 a.m., the patient received Oxycodone 30 mg for a pain level of 10/10 which still was 10/10 an hour later. Further review of the medical record revealed no documentation the physician was notified of the patient's pain level and continued lack of pain control.

Continued review of the MAR dated July 13, 2012, revealed at 8:28 a.m., the patient received the scheduled dose of Oxycontin 60 mg but no pain level was documented. Further review of the MAR dated July 13, 2012, revealed at 9:27 a.m., nursing documented the patient was not satisfied with pain control and "...patient states...is in severe pain but is falling asleep..." Continued review of the medical record revealed no documentation the physician was notified of the patient's pain level or dissatisfaction with pain control. Continued medical record review reveled no use of non-pharmacologic interventions to control the pain. Further medical record review dated July 13, 2012, revealed the Physician's Assistant observed the patient at 10:06 a.m. but made no changes in pain medications.

Review of the MAR dated July 13, 2012, revealed, at 11:08 a.m., the patient received Oxycodone 30 mg and was discharged to home at 11:39 a.m. Continued medical record review revealed no documentation of a pain assessment following the administration of the Oxycodone.

Medical record review of discharge orders revealed the patient was discharged home on Oxycontin 60 mg twice daily; Oxycodone 30 mg every 4 hours as needed; and Tizanidine 4 mg three times daily as needed for spasms.

Review of the facility policy entitled Pain Management revealed "...4. Reassessment after pain medication administration will be documented in the computer. 7. If current pain regimens are not effective in controlling the patient's pain, i.e the patient's pain is not relieved or is getting worse, the physician should be called for further instructions. 8. Techniques to be considered for non-pharmacologic management of pain may include the following: repositioning, cutaneous stimulation, and cognitive-behavioral interventions such as relaxation, distraction, and imagery..."

Medical record review revealed a complete head-to-toe assessment was completed on July 12, 2013, at 8:00 p.m. Continued medical record review revealed no documentation of a head-to-toe assessment of the patient on July 13, 2013.

Review of the facility policy entitled Plan of Care: Patient Assessment and Discharge Plan, revealed "Shift Assessment:
1. All patients must have a shift assessment completed no less that every 12 hours.
2. The shift assessment must include all body systems and address identified patient needs or problems.
3. A registered nurse is responsible to seeing that a shift assessment is completed for each patient.
4. Education and patient outcomes are addressed on each shift assessment"

Interview with the Oncology Nurse Manager on July 24, 2013, at 12:30 p.m., in the Executive Conference Room, confirmed no assessment was completed after administration of analgesic on July 13, 2012, at 11:08 a.m. Continued interview with the Nurse Manager confirmed the patient did not have a shift assessment for the day shift, on July 13, 2013. Further interview with the Nurse Manager confirmed the physician was not notified that pain control was inadequate.
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
Based on medical record review, facility policy review, and interview, the facility failed to reassess a patient prior to discharge to determine if the current plan was adequate for one (#15) of seventeen patients reviewed.

The findings included:

Review of the facility policy entitled Plan of Care: Patient Assessment and Discharge Plan, revealed "...3. The Discharge Instructions address: i. brief statement of condition/status upon discharge..."

Medical record review of nursing notes revealed no nursing assessment completed on the patient the morning of July 13, 2012. Medical record review of the discharge instructions revealed no statement of the patient's condition upon discharge.

Interview with the Oncology Nurse Manager on July 24, 2013, at 12:15 p.m., in the Executive Conference Room, confirmed the discharge instructions did not have a brief summary of the patient's status as required per hospital policy.