HospitalInspections.org

Based on document review and interview, it was determined for 1 of 2 (Pt #1) patient's records reviewed, the Hospital failed to ensure registered nursing assessments to evaluate patient needs, change in health status, and response to interventions were performed in accordance with its policy and/or patient care needs. This has the potential to affect all patients who receive care by the Hospital with an average daily census of 365 patients.

Findings include:

1. The policy titled, "Pain Management and Practice Standards" (dated by the Hospital 8/2020) was reviewed on 4/7/2021. The policy noted pain management guidelines as, "i. Pain- Mild (1-3): non-opiod analgesic ... ii. Pain- Moderate (4-6): Low dose opiods ... iii. Pain- Severe (7-10): High dose opiods are recommended ... 5. Reassessment of pain to be done within 60 minutes of each intervention (pharmacologic and non-pharmacologic)..."

2. Pt #1 Start of Care: 1/22/2021
Diagnoses: Heart Failure and Atrial Fibrillation. The record was reviewed 4/6/2021 thru 4/9/2021.
A. Pain management / response to interventions:
1) On 2/1/2021 at 4:00 AM, the record noted Pt #1 rated his/her pain at a level 8, agitated and was in severe distress; was treated with Tylenol 650 mg (milligram) at 4:51 AM; at 5:51 AM, the pain was reassessed as a level 7 and as severe, although documented as "effective" pain management.
2) On 2/1/2021 at 8:00 AM, the record noted Pt #1 rated his/her pain at a level 10 and was agitated; was treated with an opiod medication at 8:33 AM; at 9:00 AM, the pain was reassessed as a level 10.
3) On 2/1/2021 at 7:00 PM, the record noted pain was reassessed as a level 5, 10 hours after the previous pain assessment; was treated with an opiod medication at 7:32 PM; and was not re-evaluated prior to a change in condition at 8:44 PM.

B. Change in health status:
1) The record noted the Magnetic Resonance Imaging (MRI) test was canceled on 2/1/2021 at 2:12 PM.
2) The Rapid Response Team Text (RRT, a team of providers that respond emergently for patient who have an acute change in condition) dated 2/1/2021 at 8:44 PM noted, "On arrival pt (patient) placed in Trendelenburg (on back with feet elevated higher than head), manual bp (blood pressure) reading 60 systolic with doppler... Per... (significant other) pt has been vomiting, which started after he/she went for an MRI ... States it was a brown color..."
3) A nurse's note dated 2/1/2021 at 9:00 PM noted, "Pt lethargic and having coffee ground emesis pulse weak and doppled. Unable to obtain b/p ...."
4) The record lacked documentation the nurse notified the physician of the coffee ground emesis when it began and/or prior to the patient's change in condition.

3. During an interview on 4/8/2021 at approximately 10:00 AM, E#25 (Nursing Outcomes Facilitator) reviewed Pt #1's record and verbally agreed there was a 10 hour lapse in pain assessments on 2/1/2021 between 9:00 AM and 7:00 PM and stated pain should have been reassessed (in accordance with Hospital policy). E#25 verbally agreed the record lacked documentation the Physician was notified when Pt #1's coffee ground emesis began and/or prior to the patients change in condition and should have been.

4. During an interview on 4/9/2021 at approximately 11:00 AM, E#23 (Systems Director of Patient Safety) verbally agreed the patient's response to nursing interventions, were not evaluated and should have been. E#23 verbally agreed pain was not appropriately managed per policy and stated, "A pain level of 7 or above is not considered effective." E#23 verbally agreed the physician should have been notified when the coffee ground emesis began.