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Based on observation, clinical record review, policy review, and staff interview, it was determined the hospital failed to provide nursing care specific to the patient's needs, to administer pain medication timely and assess the characteristics of the patient's pain when administering pain medication (A-395). The cumulative effect of these systemic practices resulted in the hospital's inability to ensure effective nursing care was provided to each patient specific to the needs of each patient.

Based on observation, clinical record review, policy review, patient and staff interview, it was determined the hospital failed to provide nursing care specific to the patient's needs (Patient # 6), to administer pain medication timely (Patient # 4) and assess the characteristics of the patient's pain when administering pain medication (Patient #'s 1, 4, 9 and 10). The total sample size was 11 and the current census at the time of the survey was 38.

Findings include:

The medication administration record (MAR) for Patient #11 was the only part of the clinical record reviewed and was completed on 08/15/12.
The MAR revealed the physician ordered morphine sulfate, a narcotic pain medication, two milligrams to be given to the patient intravenously every two hours as needed for severe pain. This order was placed by the physician on 06/27/12 at 7:18 P.M.
The MAR revealed the patient was given two milligrams of morphine sulfate intravenously on 06/27/12 at 9:54 P.M., and on 06/28/12 at 6:16 A.M., and 8:33 A.M.. The electronic MAR lacked documentation of the location, severity, or any characteristics to describe Patient #11's pain for which the medication was given.
On 08/14/12 at 1:23 P.M., Staff A verified these findings.
Review of the facility's policy " Pain Management Plan ", effective 01/2003, was completed on 08/14/12. The review revealed "If pain is identified, the patient should be further assessed; the following should be documented: pain location, pain character, pain duration, pain intensity or severity ... " The policy was otherwise mute on the frequency of when pain is assessed in relation to when pain medication is administered.

The clinical record review for Patient # 4 was completed on 08/15/12. This patient was admitted to the hospital on 05/08/12, with diagnoses that included metastatic cancer, malnutrition and a history of prostate cancer.
The patient was ordered a narcotic pain medication in pill form at admission to be given every six hours as needed. Two days later, on 05/10/12, the physician ordered a narcotic pain medicine to be given intravenously every six hours as needed. These two medications were given alternately so the patient could receive pain medication every three hours as needed.
The patient received the ordered pain medicine intravenously on 05/13/12 at 7:53 P.M., without documentation of the location, severity or characteristics of the patient's pain.
The patient received the ordered pain medicine intravenously on 05/16/12 at 5:32 A.M., without documentation of the location, severity or characteristics of the pain.

The pain pill was changed to a liquid form on 05/17/12 when it became difficult for the patient to swallow.
The patient received the liquid pain medicine on 05/17/12 at 8:35 P.M., without documentation of the location, severity or characteristics of the pain.
The patient received the liquid pain medicine on 05/18/12 at 00:59, and 3:41 P.M., without documentation of the location, severity or characteristics of the pain.
This physician for this patient ordered a PCA (patient controlled analgesia) pump with morphine sulfate on 05/21/12 at 9:26 A.M., for the extreme pain the patient was exhibiting. The clinical record review revealed the PCA pump was started on 05/21/12 at 2:30 P.M.
Staff B and D were interviewed on 08/14/12 at 2:30 P.M., and confirmed these findings. Staff B and D were unable to explain why the PCA pump for the administration of the patient's pain medication was delayed for more than five hours.
Staff B stated that the nursing staff is required to check the clinical record for physician orders once per shift. The nursing shifts are 12 hours long.

A review of the hospital's complaint log was completed on 08/13/12. The months of April, May, and June, 2012 were reviewed. In April, 2012, five patients complained about waiting for pain medication. In May, and June, 2012, three patients, for each of those months, complained about the delay in receiving pain medication.

This finding was confirmed with Staff B on 08/14/12 at 4:00 P.M.









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The clinical record review for Patient #6, was completed on 08/14/12. The clinical record revealed the 57-year-old patient's care began with the facility on 07/27/12, with diagnoses of end stage renal disease, coronary artery disease, and diabetes. A nursing assessment, dated 08/10/12 at 7:48 A.M., stated the patient was blind in both eyes.

On 08/14/12 at 8:55 A.M., Patient #6 was observed sitting up in bed with her/his breakfast on a bedside table positioned beside the bed and just out of the patient's reach.

On 08/14/12 at 9:00 A.M., the surveyor accompanied Staff E to the medication room to obtain medication for a different patient, Patient #8. In the medication room the surveyor observed six clinical staff members congregating.

On 08/14/12 at 9:15 A.M., the surveyor observed Patient #6's breakfast unmoved and untouched. In an interview, at that time, the patient stated he/she had been waiting for at least 30 minutes for assistance with eating her/his breakfast.

On 08/14/12 at 9:24 A.M., the surveyor observed staff reheat the breakfast tray and assist Patient #6 with eating.

On 08/14/12 at 9:44 A.M., during an interview with the aide (Staff F), who assisted Patient #6 with eating, Staff F stated Patient #6 ate all of the breakfast except for the eggs because they were too hard.

Review of the patient's care plans revealed nothing specific regarding the patient's blindness to direct staff on what kind of interventions to use, and when to use them (particularly at mealtimes), to accommodate the patient's blindness.

On 08/15/12, during an interview, Staff A confirmed the clinical record lacked a specific care plan that addressed how the nursing staff were to intervene to accommodate the patient's blindness.


The clinical record review for Patient #1 was completed on 08/14/12. The clinical record review revealed the 63-year-old patient was admitted to the facility on 07/17/12. A physician ' s progress note, dated 08/10/12, stated the patient had a history of an abdominal wound. The note stated the patient had had an enterocutaneous fistula, status post takedown with abdominal wall reconstruction that was complicated by a compromised skin graph, and that Patient #1 had "recently" completed a course of intravenous antibiotic therapy for "superinfected" wounds.

The clinical record revealed the patient was prescribed a sustained release narcotic (for pain control) 120 milligrams every 12 hours on 08/09/12. On 08/11/12, 2 milligrams of a narcotic every four hours, as needed, for pain control was ordered. This was in addition to the 07/19/12, order for 15 milligrams of an immediate release narcotic to be administered every eight hours, as needed.

On 08/10/12 at 6:13 P.M. Patient #1 was given a dose of 15 milligrams immediate release narcotic. The clinical record lacked information regarding; where the pain was located, the characteristics of the pain, and the severity of the patient's pain.
A post pain medication assessment was conducted at 8:00 P.M. (almost two hours later) and indicated the patient said the pain was "decreased" without any additional details.
On 08/11/12 at 12:42 P.M., another 15 milligrams dose was given and the pain's severity, characteristics and location was not documented. A post pain medication assessment was conducted on 08/11/12 at 12:55 A.M., and documented the pain medication was "effective", but nothing more.
On 08/12/12 at 1:25 P.M., another 15 milligrams dose was given and the record lacked documentation of the patient's pain's severity, characteristics and location. At 2:25 P.M., the post pain medication assessment documented the pain medication was "very effective."
On 08/13/12 at 11:50 A.M., Patient #1 was given a 15 milligrams dose without documentation of the severity, characteristics or location of the patient's pain. At 1:50 P.M. (almost two hours later) the post pain medication assessment stated the pain medication was " somewhat effective."
On 08/14/12 at 4:30 A.M., Patient #1 was administered a 15 milligram dose for sharp, stabbing right knee pain, the severity rated as a seven on a scale of 0 to 10, with 10 being the worst. At 5:50 A.M., the post pain medication assessment stated the pain medication was "somewhat effective " but gave no further description.

On 08/12/12 at 4:44 P.M., Patient #1 was given 2 milligrams of a narcotic for pain. The record lacked documentation of the location of the pain, the pain's characteristic, or severity. A post pain medication assessment conducted at 5:44 P.M., stated the pain medication was "very effective" but lacked further description of the characteristics of the patient's pain.
On 08/13/12 at 9:00 A.M., the patient was given another dose of 2 milligrams of a narcotic. The record lacked documentation of the location of Patient #1's pain, its characteristic, and severity. A post pain medication assessment conducted at 10:00 A.M., stated the pain was " somewhat effective " and no other details were documented.
On 08/13/12 5:36 P.M. Patient #1 was given a dose of 2 milligrams of a narcotic. The record stated the patient had achy pain to the right knee and coccyx and was the severity was rated as a 7 on a zero to ten scale. A post pain medication assessment conducted at 6:36 P.M., stated the pain medication was "somewhat effective", and nothing further was documented.

On 08/14/12 at 8:51 A.M., Patient #1 was given 120 milligrams of the sustained release narcotic.
The clinical record lacked documentation of the location, severity and other descriptive characteristics of Patient #1's pain, when the patient was given: 120 milligrams of the sustained release narcotic on 08/13/12 at 8:14 A.M., 2 milligrams of the ordered narcotic at 9:00 A.M., ; and 15 milligrams of the immediate release narcotic at 11:50 A.M. .
During the afternoon of 08/13/12, Staff A confirmed the clinical record lacked documentation of pain assessments coinciding with the administration of the 120 milligrams sustained release narcotic, the 2 milligrams of a narcotic, and the 15 milligrams of the immediate release narcotic to be take for the morning of 08/13/12.

The clinical record review for Patient #9 was completed on 08/14/12. The record revealed the 41-year-old patient was admitted to the facility on 07/24/12 with a diagnosis of acute respiratory failure, and a past medical history of multiple occurrences of endocarditis with valve replacement times three, and sternal wound infection. The clinical record revealed the patient had one milligram of a narcotic ordered every four hours, as needed, for mild pain.
The clinical record revealed Patient #9 received one milligram of the ordered narcotic on 08/11/12 at 10:54 A.M., on 08/12/12 at 10:52 A.M., on 08/12/12 at 3:07 P.M. The clinical record lacked documentation of the location, the descriptive characteristics, and the severity of the patient's pain at those times.
On 08/14/12 at 12:15 P.M., Staff A verified the lack of the documentation of a pain assessment in the medication documentation.

The clinical record review for Patient #10 was completed on 08/15/12. The 83-year-old patient was admitted to the facility on 06/01/12, with a diagnosis of acute respiratory failure. A physician's progress note dated 06/04/12 stated the patient was being treated for diabetes, status post partial sigmoidectomy for cancer, status post peritonitis, and dehiscence.
The clinical record revealed the patient had five milligrams of a narcotic ordered every four hours for moderate pain. The patient received five milligrams of a narcotic on 06/14/12 at 6:45 P.M., on 06/16/12 at 3:31 P.M., and on 06/19/12 at 10:11 P.M. The record lacked documentation of the location, severity and descriptive characteristics of Patient #10's pain.
On 08/14/12 at 1:23 P.M. Staff A verified the above findings.

This deficiency substantiates Complaint Number OH00066270