HospitalInspections.org

Based on medical record review, policy review and interview, the facility failed to ensure nursing assessments were completed every 12 hours in accordance with the facility's policy for three (Patient #1, 2 and 3) of ten medical records reviewed. The facility failed to ensure pain assessments and reassessments were completed in accordance with the facility's policy for five (Patient #1, 3, 5, 9 and 10) of ten medical records reviewed. The facility failed to complete assessments and evaluation of care and follow physician orders for one (Patient #8) of ten medical records reviewed. The facility census was 20.


Findings include:


The facility's Clinical Services Policy and Procedure was reviewed. The policy stated to ensure quality patient care, certain standards of care must be upheld. The following table outlines basic tasks and designates the minimum frequency with which these tasks must be performed to maintain quality care. A specific physician order will supersede the minimum frequencies noted below. Vital signs will be obtained every 12 hours. A systematic physical assessment will be completed every 12 hours and as condition changes.

1. Patient #1 was admitted to the facility on 05/21/16 with a diagnosis of Infection with Bacteremia, Acute Kidney Injury, Hypertension, Respiratory Insufficiency, Diabetes and Depression. The medical record contained one documented shift assessment for 06/06/16 completed at 4:31 PM. The next documented shift assessment was completed on 06/07/16 at 2:04 PM.

The findings were shared with Staff G on 06/08/16 at 9:02 AM and confirmed.

2. Patient #2 was admitted to the facility on 05/28/16 with a chief complaint of persistent nausea, vomiting and inability to tolerate oral intake. The medical record contained one documented shift assessment for 06/03/16 completed at 11:48 AM. The shift assessments completed before and after the 06/03/16 shift assessment were at 9:00 PM on 06/02/16 and at 1:00 AM on 06/04/16.

The findings were shared with Staff G on 06/08/16 at approximately 9:10 AM and confirmed.

3. Patient #3 was admitted to the facility on 05/20/16 with a diagnosis of Short Bowel Syndrome and Intestinal Ischemia. The medical record review for Patient #3 revealed the facility performed a shift assessment on 06/06/16 at 9:19 AM and on 06/07/16 at 3:00 AM. The medical record did not contain documented shift assessments in between the two assessments.

The findings were shared with Staff G on 06/08/16 at approximately 9:30 AM and confirmed.


The facility's Pain Management, Assessment and Intervention Protocol was reviewed. The protocol stated all patients will be assessed for pain upon admission. If no pain is indicated, the patient will be assessed every shift (12 hours) thereafter. If pain stated, the patient will be assessed about every four hours. The nurse should inform the patient that a report of "4" or more will receive some type of intervention. If the patient refuses offered intervention after verbalizing a level four or more, the nurse will accept and document the patient's stated wishes.

4. The medical record review for Patient #1 revealed Patient #1 complained of pain as follows:
06/07/16 at 9:42 PM - pain of 8
06/07/16 at 5:43 PM - pain of 8
06/07/16 at 3:00 PM - pain of 3
The medical record did not include documentation of the pain type, location, frequency, onset, interventions or response to interventions.

On 06/06/16 at 10:30 PM, Patient #1 was assessed as having pain of 10. The next documented reassessment of pain in the medical record was on 06/07/16 at 4:26 AM, greater than four hours later.

5. Patient #3 was admitted to the facility on 05/20/16 with a diagnosis of Short Bowel Syndrome and Intestinal Ischemia. Patient #3 was assessed as having no pain on 06/06/16 at 8:43 AM. The next documented pain assessment in the medical record was on 06/07/16 at 4:57 AM. Patient #3 complained of pain of six on 06/07/16 at 5:20 PM. The medical record did not include documentation of the pain type, location, frequency, onset, interventions or response to interventions. The next documented pain assessment in the medical record was on 06/08/16 at 12:18 AM.

On 06/05/16 at 10:40 PM, Patient #3 was assessed as having a pain score of seven. The medical record did not include documentation of the pain type, location, frequency, onset, interventions or response to interventions.

6. Patient #5 was admitted to the facility on 06/03/16 with a diagnosis of Acute Respiratory Failure and Congestive Heart Failure. Patient #5 was assessed as having pain of eight on 06/07/16 at 2:17 pm. There were no interventions documented on the pain assessment. The next documented pain assessment was on 06/07/16 at 8:00 PM. On 06/06/16 at 10:14 AM, Patient #5 was assessed as having pain of nine. The medical record did not include documentation of the pain type, location, frequency, onset, interventions or response to interventions. On 06/06/16 at 6:16 AM, Patient #5 was assessed as having pain of seven. The medical record did not include documentation of the pain type, location, frequency, onset, interventions or response to interventions. On 06/05/16 at 1:39 PM, Patient #5 was assessed as having pain of ten - worst possible. The medical record did not include documentation of the pain type, location, frequency, onset, interventions or response to interventions.

7. Patient #9 was admitted to the facility on 05/27/16 with a diagnosis of Coronary Artery Disease, Pneumonia, Severe Anemia and Sepsis. Patient #9 was assessed as having pain of eight on 06/09/16 at 2:36 AM. The medical record did not include documentation of the pain type, location, frequency, onset, interventions or response to interventions.

8. Patient #10 was admitted to the facility on 05/31/16 with a primary diagnosis of Respiratory Failure. Patient #10 was assessed as having no pain on 06/08/16 at 7:43 AM. Patient #10's next documented pain assessment was on 06/09/16 at 8:00 AM, greater than 12 hours later. Patient #10's pain was assessed as no pain on 06/06/16 at 4:48 AM. Patient #10's next documented pain assessment was on 06/07/16 at 9:04 AM, greater than 12 hours.

Review of policy and procedure for clinical routine, guidelines and protocol of patient care (revised 01/01/16) revealed the facility to ensure quality patient care, certain standards of care must be upheld. Activity/Mobility of bedfast patients turned with documentation of position patient every 2 hours.

9. Review of Patient #8's physician orders for repositioning (start date 04/21/16) revealed Patient #8 was to be repositioned every two hours. Review of the nursing note (dated 04/26/16) revealed the patient was repositioned at 6:06 AM and 9:04 AM which was more than every two hours. Review of nursing note (dated 05/03/16) revealed the patient was repositioned at 8:13 AM and 11:24 AM which was more than every two hours.

Interview with Staff A on 06/09/16 at 10:00 AM confirmed the above findings.







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