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.

STEWARD SEBASTIAN RIVER MEDICAL CENTER 13695 US HWY 1 SEBASTIAN, FL 32978 Sept. 5, 2018
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview, clinical and administrative record review, the facility failed to implement the patient's plan of care by ensuring the nursing staff consistently performed pain assessments every shift and after the administration of pain medication for 1 of 6 sampled patients (Patient # 6) and failed to ensure the facility staff implemented the prescribed wound care treatment for 1 of 6 sampled patients (Patient # 1).

The findings included:

1) Review of the clinical record for Patient # 6 revealed the patient was admitted on [DATE] and was status post left Above the knee Amputation. The patient also has a Stage IV pressure ulcer on her buttock which is dressed with a Wound Vac. The physician prescribed on 08/22/18 for the patient to receive Tramadol 50 mg every 8 hours as needed. An intervention noted on the patient's Plan of Care include Pain Assessment every 12 hours. Review of the patient's electronic record failed to provide evidence the patient was assessed for pain every 12 hours and was not consistently assessed for the effectiveness of the administration of pain medication after receiving the pain medication as follows:
There was no pain assessment five times on the Day shift on 08/28/18, 08/30/18, 08/31/18, 09/02/18 and 09/04/18.
On 08/23/18, the nurse administered the Tramadol at 4:43 PM, however the nurse noted foot pain but did not provide a numeric value for the severity of the pain. The nurse noted a reassessment of the pain at 10:26 PM (almost 4 hours later) and qualified the patient's pain as 4 out of 10 on the pain scale.
On 08/26/18 at 6:21 AM, the nurse administered the Tramadol for pain of 7. However there is no timely follow up reassessment to determine the effectiveness of the administered medication.

An interview was conducted on 09/05/18 at approximately 10:30 AM with the Registered Nurse, Director, Progressive Care Unit, who stated that the staff are to follow up on the administered as needed pain medication within 30 minutes to 1 hour after administering the medication to determine if the medication was effective. She also stated that the staff nurses are to assess the patient every shift for pain. The facility utilized every 12 hour shifts. She further confirmed that on the above dates, she was unable to provide evidence the nurse performed the pain assessments.

2) Review of the clinical record for Patient # 1 revealed the patient presented to the facility's emergency room on [DATE] after tripping and falling over a speed bump in the hospital's parking lot. The patient was noted to have multiple abrasions and was prescribed wound care, "General wound care and Band-Aid or 4 x 4 application."

An interview was conducted on 09/04/18 at approximately 11:00 AM with Patient # 1, who had returned to the emergency room for follow up care for the injuries from the 08/31/18 fall. The patient stated he had multiple abrasions from his fall, "they didn't even clean up my wounds." My spouse "had to clean them up when I got home."

An interview was conducted on 09/05/18 at 12:35 PM with the Registered Nurse, Staff B, who provided care for the patient on 08/31/18. The nurse confirmed she did not perform wound care on the patient's abrasions. She stated she did wipe the blood off because the abrasions were bleeding. She stated she gave the patient discharge instructions to clean the wound. She further stated that she was unaware there was a wound care order. The facility has a new electronic system and the nurse stated she did not see the order from the physician to perform wound care.