HospitalInspections.org

Based on review of three (3) of ten (10) medical records (#2, #7, #9), staff interview and review of facility documents, it was determined that the facility failed to timely address the complaint of pain and ensure that a pain reassessment is completed in accordance with facility policy.

Findings include:

Reference: Facility policy titled, "Pain Management, Assessment And Intervention protocol" states, "...E. Re-Assessment: ...iii Pain will be reassesses 30-60 minutes following a pain reduction intervention. ...v. If patient is being managed for pain, pain level will be assessed about every 4 hours [sic]..."

1. Review of Medical Record #2 on 11/4/2021, revealed the following:

a. At 10:39 AM, Patient #2 received a scheduled Lidocaine 4% patch to his/her right hand; Oxycodone 20 MG (milligram) tablet and Lyrica 75 MG for right hand pain.

b. There was no evidence that a pain reassessment was completed 30-60 minutes after the pain reduction intervention.

2. Review of Medical Record #7 on 11/4/2021 revealed the following:

a. On 11/3/2021 at 2000 (8:00 PM), Patient #7 complained of moderate pain. Oxycodone 5 MG was administered at 2228 (10:28 PM), two (2) hours twenty-eight (28) minutes after the initial complaint of pain.

3. Review of Medical Record #9 on 11/4/2021 revealed the following:

a. On 11/1/2021 at 2000 (8:00 PM), Patient #9 complained of pain 5/10 (five out of ten) on a numeric pain scale. Tylenol 650 MG was administered at 2200 (10:00 PM), two (2) hours after the initial complaint of pain.

b. There was no evidence of a reassessment of pain until the following day on 11/2/2021 at 0643 (6:43 AM).

4. Staff #3 confirmed the above findings.

Based on staff interview, medical record review and document review, it was determined that the facility failed to ensure that its Medication-Anticoagulation Therapy Policy is implemented by ensuring that the two nurse verification is completed when a bag of Heparin is hung and is administered as ordered by the physician.

Findings include:

Reference #1: Facility policy titled, "Medication-Anticoagulation Therapy Policy" states, "PURPOSE: To provide safe and effective anticoagulant usage, monitoring, and dosing. ...Heparin PURPOSE: To establish guidelines for the prescribing and monitoring of Heparin in order to ensure that it is used safely and effectively. PROCEDURE: ...5. Two RN's will confirm and sign the Heparin Infusion Administration Record and post High Risk Medication sticker in the order section of the chart and on Heparin medication bag with date, time and rate for all of the following: ...6. Heparin drip must be infused via an IV [intravenous] administration pump. Pump settings will be verified by two (2) RN's...8. The RN will follow the Heparin Adjustment Scale and will: ...b. Start the drip at rate selected by physician on the order form. ..."

1. Review of Medical Record #1 on 11/3/2021 revealed the following:

a. A physician's order acknowledged by a nurse on 2/14/20 at 1300 (1:00 PM) stated, "Unfractionated heparin 80 units/kg [kilogram] IV [intravenous] bolus followed by maintenance infusion of 18 units/kg/hr [hour] follow heparin adjustment scale below to maintain aPTT [activated partial thromboplastin time] of 37-55 sec [seconds], until infusion discontinued by physician"

b. The Heparin Drip Documentation Tool states, "Patients's weight 76 kg...," indicating that Patient #1 should have received Heparin infusing at 13.7 ml/hr [milliliter per hour].

c. On the Heparin Documentation Tool, the line dated 2/14/20 at 1415 (2:15 PM), when the therapy was initiated, there were two (2) RN initials to verify the administration.

d. On the Patient Care flow sheet dated 2/14/20, in the section identified as "Intake (In CC [cubic centimeters])", states, "IV [intravenous]: Hep [Heparin] gtt [drops]." The time of Heparin administration and intake amount was recorded as follows:

(i) 1400-1459 137

(ii) 1500-1559 137

(iii) 1600-1659 137

(iv) 1700-1759 137

(v) 1800-1859 137

(vi) 7A-7P TOTAL 685

e. One (1) cc is equal to one (1) ml (milliliter). Patient #1 received 137 mls per hour instead of 13.7 mls per hour.

f. Upon interview on 11/3/2021, Staff #3 stated that a total of three (3) bags of Heparin containing 250 mls were hung to be administered intravenously.

(i) There was no documentation on the Heparin Drip Documentation Tool that bag #2 and bag #3 were hung.

(ii) There was no evidence that a double check by two (2) licensed nurses was conducted prior to the administration of bag #2 and bag #3.

2. The above findings were confirmed with Staff #3.

A. Based on review of Medical Record #1, staff interview and document review, it was determined that the facility failed to ensure that a physician order for heparin is dated and signed.

Findings include:

Reference: Facility policy titled, "Orders: Written and Verbal" states, "...Procedure...1) All orders must be dated, timed, and signed by the ordering practitioner..."

1. Review of Medical Record #1 on 11/4/2021 revealed the following:

a. Patient #1 was admitted on 2/7/20.

b. On the Weight Based Heparin Protocol order sheet, the box next to "Unfractionated heparin 80 units/kg [kilogram]/IV [intravenous] bolus followed by maintenance infusion of 18 units/kg/hr [hour]" was checked.

c. There was no date or time next to the physician signature, therefore, it was unable to be determined when the order was written. The order was acknowledged by a nurse on 2/14/20 at 1300 (1:00 PM).

2 Staff #3 confirmed the above findings.

B. Based on review of one (1) of one (1) medical record (#1), staff interview and document review, it was determined that the the facility failed to ensure that a physician's Heparin order is clear.

Findings include:

Reference: Facility policy titled, "Orders: Written and Verbal" states, "...Procedure...3) Read the Physician/AHP order carefully. Medication orders must include ...b.Dose, frequency and route c. Specific instructions for use, if applicable...4) If the criteria in 3a-f are complete or inaccurate, or if an order set is utilized and incomplete, clarification is needed with the ordering provider prior to implementing the written orders. ... B. Clarification of Physician/AHP orders ...2) If the orders are not clear, call the Physician/AHP for verbal clarification prior to implementation. ..."

1. Review of Medical Record #1 on 11/3/2021 revealed the following:

a. On a preprinted order set dated 2/15/20 at 1:20 PM, the box next to "Unfractionated heparin 80 units/kg [kilogram] IV [intravenous] bolus followed by maintenance infusion of 18 units/kg/hr [hour]..." was checked, followed by "no bolus" handwritten.

b. There was no evidence that the Heparin bolus was clarified.

c. Upon interview on 11/3/2021, Staff #3 confirmed that the order was unclear and should have been clarified.