HospitalInspections.org

Based on review of documents and interviews with facility staff, the facility failed to assure that the registered nurses evaluated the care of each patient as pain assessments were not performed in accordance with facility policy in 1 of 1 patient records reviewed.

The findings were:
The facility policy entitled "Pain Management" with a revised date of 8/8/11 reflected in part "Pain should be assessed at admission and be reassessed at regular intervals. ... Assess pain at least every two hours and during rest, activity, and through the night (when pain is usually heightened). Keep in mind that the ability to sleep doesn't indicate the absence of pain."

The medical record of patient #1 was reviewed on 9/5/12 and revealed the following findings.

The nurses' notes reflected the following entries regarding patient #1's pain management for 8/1/12 - 8/2/12.
8/1/12 at 0405 hydromorphone (dilaudid) 2 mg IV (intravenous) for 7 on the pain scale; decreased to 5 at 0536
8/1/12 0700 Pain management: no signs/symptoms of pain exhibited.
8/1/12 1230 hydromorphone 2 mg IV for breakthrough pain; decreased to 5 on the pain scale at 1806.
8/1/12 2104 hydromorphone 2 mg IV for 6 on the pain scale; decreased to 4 at 2230.
8/1/12 2146 Pain assessment: no signs/symptoms of pain exhibited.
8/2/12 0324 hydromorphone 2mg IV for 7 on the pain scale; decreased to 4 at 0420.
8/2/12 0800 Pain assessment: no signs/symptoms of pain exhibited.
8/2/12 1150 Pain management: no signs/symptoms of pain exhibited.
8/2/12 1218 hydromorphone 2 mg IV for 7 on the pain scale; decreased to 2 at 12:50.
8/2/12 1735 hydrocodone 7.5mg/acetaminophen 325 mg (Norco) PO (by mouth) for 8 on the pain scale; decreased to 2 at 1835.
8/2/12 2000 Pain assessment: no signs/symptoms of pain exhibited.
8/2/12 2148 hydromorphone 2 mg IV for 5 on the pain scale; decreased to 2 at 2245.

There were no pain assessments documented for the following periods of time greater than 2 hours for 8/1/12 - 8/2/12.

From 8/1/12 0000 - 0405, 4 hours 5 minutes.
From 8/1/12 0700 - 1230, 5 hours 30 minutes.
From 8/1/12 1806 - 2104, 2 hours, 58 minutes.
From 8/1/12 2230 - 8/2/12 0324, 4 hours, 54 minutes.
From 8/2/12 0420 - 0800, 3 hours, 40 minutes.
From 8/2/12 0800 - 1150, 3 hours 50 minutes.
From 8/2/12 1250 - 1735, 4 hours, 55 minutes.

In an interview on 9/5/12 at 3:00 pm in the conference room, staff #6 acknowledged that there were time intervals of more than two hours on 8/1/12 and 8/2/12 where pain assessments were not documented for patient #1.

Based on review of records and interviews with facility staff, the facility failed to ensure that verbal orders were dated, timed and authenticated within 48 hours by the prescriber or another practitioner who is responsible for the care of the patient as 4 of 5 verbal orders on the medical record of patient #1 were not authenticated within 48 hours.

The findings were:
The medical record of patient #1 was reviewed on 9/5/12 and revealed that 4 of 5 verbal orders on the medical record were not authenticated within 48 hours. In an interview on 9/5/12 at 2:40 pm in the conference room, staff #3 confirmed that the paper verbal orders were not authenticated within 48 hours and stated that there was no documentation of authentication of the verbal orders in the electronic record of patient #1.

Based on observation, review of documents and interviews with facility staff, the facility failed to ensure that specific food and dietetic services organization requirements were met as trayline accuracy assessments were not done in accordance with facility policy.

The findings were:
The facility policy entitled "Nutritional Services Performance Indicators and Quality Control" policy #H-NS 10-002, revised date 6/11 reflected in part "Policy: It is our policy to monitor quality control and performance improvement indicators, to assure safe, efficient and evidenced based operations. Procedures: 1. Quality Control: a. The following are required monitors of Quality Control: ... Trayline Accuracy (includes trayline audit and test tray) Weekly, 95% Threshold."

During an interview on 9/5/12 at 12:50 pm the nutritional services manager, staff #4 was asked to see the Trayline Accuracy Assessment forms for 2012. Staff #4 produced Trayline Accuracy Assessment forms dated 8/7/12, 8/23/12 and 8/28/12. When asked if there were any other forms, staff #4 stated that there were no other assessment forms and the trayline assessment was re-implemented on 8/7/12 in response to the complaint by patient #1's spouse. Staff #4 stated that the assessment should be done weekly.