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|LAWNWOOD REGIONAL MEDICAL CENTER & HEART INSTITUTE||1700 S 23RD ST FORT PIERCE, FL 34950||June 14, 2018|
|VIOLATION: RN SUPERVISION OF NURSING CARE||Tag No: A0395|
|Based on policy review, clinical record review and interview it was determined the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5). This failure affected 4 of 7 sampled patients (Patient #2, #4, #5, and #7) as evidenced by failure to reassess pain as specified in the facility policies and procedures and failure to follow prescription parameters for pain management.
The findings included:
Facility policy titled "Assessment and Reassessment Plan" revised 08/2017 documents the patient will be assessed and reassessed for pain according to the hospital policy for pain management."
Facility policy titled "Pain Management" revised 08/2017 documents "All patients will be reassessed for pain within one hour after pain treatment/interventions have been administered".
Clinical record reviews conducted on 06/12/18 and 06/14/18 revealed the following:
1) Physician's Orders for Patient #2 dated 06/07/18 documents Percocet 5/325 mg every four hours as needed for pain level 4-6 and Morphine Sulfate 15 mg IR every 4 hours as needed for pain level 7-10.
Review of the Mediation Administration Records and Assessment and Reassessments documentation indicates the facility staff administered pain medication with disregard to pain level parameters and in some instances the facility staff failed to reassess the patient's pain level to monitor effectiveness of the drug administration.
On 06/09/18 at 1:25 AM the patient received Percocet for a pain level of 8
On 06/09/18 at 8:13 AM Percocet was administered and there is no evidence of pain reassessment
On 06/09/18 at 3:48 PM Percocet was administered and there is no evidence of pain reassessment
On 06/09/18 at 8:47 PM Percocet was administered for pain level of 7
06/10/18 at 2:18 AM Percocet was administered for pain level of 7
06/11/18 at 1:29 PM Percocet was administered for pain level 7
06/11/18 at 8:36 PM Percocet was administered for pain level 9
06/12/18 10:31 Percocet was administered for pain level 9
On 06/08/18 at 5:23 PM Morphine was administered and there is no evidence of pain reassessment
On 06/09/18 at 11:09 AM Morphine given for pain level of pain 6
On 06/09/18 at 6:37 Morphine given for pain level of 5
On 06/10/18 at 11:25 AM Morphine given and there is no evidence of pain reassessment.
The record provides no documentation as to why the parameters were not followed.
2) Patient #7 has physician's order dated 06/08/18 for Percocet 5/325 mg every four hours for pain scale 4-6.
On 06/08/18 at 12:38 AM, the patient received Percocet 5/325 for pain level of 8. The record has no explanation as to why the deviation from the prescription parameters.
3) Patient #4 has physician's order dated 03/18/18 for Toradol 15 mg every six hours for pain. On 03/18/18 at 10:23 AM the patient received the prescribed Toradol and there is no evidence of pain reassessment.
4) Patient #5 has physician's order dated 05/27/18 for Toradol 15 mg every six hours for pain. On 05/2718 at 11:03 PM the patient received the prescribed Toradol and there is no evidence of pain reassessment.
Interview with The Vice President of Quality and Risk Management and The Director of Patient Safety conducted on 06/14/18 at approximately 11:30 AM confirmed the nursing staff did not follow the prescribed parameters for pain medication administration and confirmed the entries lacking nursing reassessment after administration of pain medications.