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SSM HEALTH ST MARY'S HOSPITAL - JANESVILLE 3400 EAST RACINE STREET JANESVILLE, WI 53546 March 13, 2014
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on medical record review, review of policy and procedure, and staff interview, the facility failed to ensure staff appropriately assessed and re-assessed for pain and met patient care needs for 3 of 7 patients receiving pain interventions out of a total universe of 10 MRs reviewed (#1, 2, 3). This deficient practice has the potential to affect all inpatients who receive pain assessments and interventions at this facility.

Findings include:

Review on 3/13/14 of hospital policy titled "Pain Assessment, Reassessment, and Management" dated 1/27/14 states "It is the patient's right to receive optimal pain assessment, management and reassessment..... pain is the fifth vital sign and will be assessed on admission and with vital signs." Under procedure guidance it states "when pain is present a pain reassessment is preformed at least every 4 hours and more often if needed". It further states "any patient care provider that has implemented a pain control mechanism will reassess the patient within one half hour of intravenous pain medication; within one hour of oral medications; and within one hour of all non-pharmacological interventions..."

Per interview with Director of Quality A on 3/11/14 at 2:45 PM, the expectation is for pain to be assessed at minimum every 4 hours with vital signs and more often if needed. Per Director of Quality A pain reassessment should occur when the medication is given, then again 30 minutes after pain medication is given IV or within an hour after pain mediation is given orally to evaluate the effectiveness of the medication.

Review of Pt #1's medical record (MR) on 3/12/13 at 12:30 PM revealed the following missed pain assessments and re-assessments:

7/19/13 at 2:00 PM Morphine (a pain medications) via IV (Intravenous) given for pain. Pain assessment documented. Next pain assessment did not occur until 3:00 PM which exceeds 30 minutes.

7/19/13 at 11:27 PM Morphine via IV given for pain. No pain assessment documented. Next pain assessment did not occur until 9:13 AM the following day.

No pain assessments occurred from 10:14 PM on 7/20/13 through 9:31 AM on 7/21/13 which exceeds the minimum of 4 hour pain assessments.

No pain assessments occurred from 7:20 PM on 7/21/13 through 9:30 AM on 7/22/13 which exceeds the minimum of 4 hour pain assessments.

7/22/13 at 9:54 PM PM Morphine via IV given for pain. Pain assessment states "crying". Next pain assessment did not occur until 11:09 PM exceeding 30 minutes.

7/23/13 at 8:07 AM Dilaudid (a pain medication) via IV given for pain. Next pain assessment did not occur until 9:07 AM which exceeds 30 minutes.

7/23/13 at 11:10 AM Dilaudid via IV given for pain. Next pain assessment did not occur until 10:02 PM exceeding 30 minutes follow up assessment for IV medication administration and minimum of 4 hour pain assessment expectation.

On 7/25/2013 at 10:40 AM Pt #1 was started on a Fentanyl patch (a pain medication that is absorbed through the skin from a patch applied to the arm, back or chest).

7/26/13 at 9:42 AM Morphine via IV given for pain. Pain assessment states "assume positive". Next pain assessment did not occur until 11:00 AM exceeding 30 minutes.

7/26/13 at 9:25 PM Morphine via IV given for pain. Pain assessment states "assume positive". Next pain assessment did not occur until 10:25 PM exceeding 30 minutes.

7/28/13 No pain assessments occurred from 9:10 AM through 8:30 PM which exceeds the minimum of 4 hour pain assessments.

7/29/13 No pain assessments occurred from 4:00 AM through 1:19 PM which exceeds the minimum of 4 hour pain assessments.

7/30/13 at 9:29 AM Morphine via IV given for pain. No pain assessment documented. Next pain assessment did not occur until 11:08 AM exceeding 30 minutes.

7/30/13 at 5:01 PM Morphine via IV given for pain. Pain assessment states "assume positive." Next pain assessment did not occur until 9:21 PM exceeding 30 minutes.

7/31/13 at 1:28 AM Morphine via IV given for pain. No pain assessment documented. Next pain assessment did not occur until 2:13 AM exceeding 30 minutes.

7/31/13 at 11:08 AM Morphine via IV given for pain. Next pain assessment did not occur until 6:28 PM exceeding 30 minutes for follow up pain assessment and 4 hour minimum pain assessment.

8/1/13 at 12:57 AM Morphine via IV was given for pain but no pain assessment was documented. Next pain assessment did not occur until 1:42 AM.

8/2/13 at 8:55 PM Morphine via IV was given for pain and pain assessment was completed. Next pain assessment did not occur until 10:00 PM exceeding 30 minutes.

8/5/13 at 9:20 AM Morphine via IV was given for pain and pain assessment was completed. Next pain assessment did not occur until 10:00 AM exceeding 30 minutes.

8/5/13 at 8:58 PM Morphine via IV was given for pain but no pain assessment was documented. Next pain assessment did not occur until 9:25 PM exceeding 30 minutes.


Review of Pt #2's medical record on 3/11/13 at 2:40 PM revealed the following missed pain assessments and re-assessments:

12/17/13 at 12:26 AM Loritab (an oral pain medication) given for pain but no pain assessment was documented. Next pain assessment did not occur until 5:40 AM exceeding 1 hour.


Review of Pt #3's medical record on 3/11/14 at 11:40 AM revealed the following missing pain assessments and re-assessments:

9/26/13 at 2:13 PM Morphine via IV was given for pain but no pain assessment was documented and no re-assessment was documented.

10/3/13 at 5:10 AM Morphine via IV was given for pain but no pain assessment was documented. Next pain assessment did not occur until 8:00 AM exceeding 30 minutes.