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Based on review of Patient #1's clinical record and interviews with the Medical Director and the Director of Quality Improvement, the Hospital failed to ensure that the corrective action plan developed in response to Patient #1's overmedication was implemented in a timely manner.

Findings include:

Please Refer to A-395 for information regarding medication administration and nursing assessment.

Surveyor #1 and Surveyor #2 interviewed the Director of Quality Improvement on 12/11/12 at 9:00 A.M. and the Medical Director on 12/11/12 at 11:16 A.M. The Director of Quality Improvement and the Medical Director said an investigation was conducted. The Medical Director said that the Flomax, in combination with the narcotics, may have contributed to Patient #1's condition as it can cause a lowering of the blood pressure. The Medical Director and the Director of Quality Improvement said that they identified several areas for improvement that included:

1) Educate the nurses on the availability and administration of Narcan (narcotic reversal agent) and usage.

2) Clarify and educate nurses about rechecking vital signs to verify if there is an actual change and communicating that change to the Physician.

3) Review and clarify Rapid Response Criteria as to what constitutes an actual change in patient condition.

4) Involve Pharmacy in developing how a pain medication order may be written to prevent this type of occurrence, for example, using dose limitations in accordance with the Pain Policy.

5) Establish better physician to physician Hand-Off Communication especially to physician's taking call and covering patient care in the off shifts.

At the time of the Survey, the only corrective action completed was a Quality Line e-mail communication to nursing staff about the evaluation of abnormal vital signs and Rapid Response criteria. A process to verify receipt of this Quality Line by nursing staff was not evident.

Based on review of the Pain Management Policy, Patient #1's clinical record and interviews with Nurse #1, the Chief Nursing Officer (CNO) and Nurse #2, the Hospital failed to ensure that Patient #1's vital signs and level of sedation were assessed according to policy while receiving multiple doses of Morphine.

Findings include:

The Hospital Policy titled Pain Management, issued 11/2001 and revised 12/10/10, indicated that a reassessment of pain was to be documented on the Pain Reassessment Intervention Record within one hour of administration of a pain medication. The Policy indicated that patients with acute pain will have their vital signs and sedation level evaluated with each dose until stable for 24 hours. The Policy indicated that if an unacceptable pain level is not reached within 2 hours, the nurse is to notify the physician, nurse practitioner, or physician assistant.

The Medication Administration Record (MAR), dated 10/3/12 to 11/1/12, indicated that Patient #1 had diagnoses including Devic's Disease (a neuromuscular disorder), diabetes, anxiety, depression, quadriplegia (paralysis of upper and lower extremities) and neurogenic bladder (lack of bladder control due to a spinal cord or nerve injury). The MAR indicated that Patient #1's medications included Methadone (a narcotic medication used to manage severe pain), Alprazolam (anti-anxiety medication), Diazepam (anti-anxiety medication, muscle relaxer), Trazodone (medication for depression and anxiety) and Baclofen (medication to treat muscle spasm).

The 2011 Nursing Drug Handbook (Lippincott, Williams and Wilkins) indicated that side effects for Methadone, Diazepam, Alprazolam, Baclofen, and Trazodone included drowsiness and sedation.

The Nurses Notes, dated 10/30/12 at 1:48 P.M., indicated that Patient #1 complained of
#10 (numeric pain scale where 0 is no pain and 10 is the most severe) back and abdominal pain with blood noted in his/her urine. The Nurses Notes indicated that Patient #1 was started on Macrodantin (an antibiotic used to treat urinary tract infections) and oxycodone (narcotic pain reliever) for pain.

The Physician Orders, dated 10/31/12 at 10:00 A.M. indicated that the Oxycodone was discontinued and Morphine 5 mg IM (a narcotic pain releiver) stat (immediately) was to be given and then every 1 hour as needed for a 6-10 pain rating.

The Physician's Orders, dated 10/31/12 at 11:00 A.M., indicated the Physician ordered Flomax (a medication used to help pass a kidney stone) 0.4 mg by mouth. Side effects include somnolence (a state of drowsiness or sleepiness).

The Nurses Notes, dated 10/31/12 at 12:14 P.M., indicated that Patient #1 received the stat dose of Morphine at 10:25 A.M. The Nurses Notes indicated that Patient #1 was scheduled to go for diagnostic x-rays to check for a kidney stone.

The Blood Pressure and Respiratory Rate History indicated that on 10/31/12 at 11:00 A.M., Patient #1's blood pressure was 158/80 (normal range 90/60 to120/80) with a respiratory rate of 18 (normal 12 to 18 breaths per minute).

The MAR indicated that Patient #1 received additional doses of Morphine 5 mg IM at 12:45 P.M. and 3:25 P.M. for a pain rating of 10.

The Blood Pressure and Respiratory Rate History did not indicate vitals signs were taken at 12:45 P.M.

The Blood Pressure and Respiratory Rate History indicated that on 10/31/12 at 4 P.M., Patient #1's blood pressure was 70/54 with a respiratory rate of 16. Nursing documentation did not indicate that the Physician was called at this time.

The Blood Pressure History, dated 9/29/12 to 11/6/12, indicated that Patient #1's blood pressure ranged from a low of 70/46 (on 10/13/12) to a high of 159/91 (on 10/24/12).

Surveyor #2 interviewed the Medical Director on 12/11/12 at 11:16 A.M. The Medical Director said that patients with neuromuscular disorders have labile (fluctuating) blood pressures.

The Physician Orders, dated 10/31/12 at 4:25 P.M., indicated that a Duragesic 25 mcg patch (an external skin patch which releases a narcotic pain medication) was ordered for Patient #1.

The MAR indicated that Patient #1 received Morphine 5 mg IM at 5:30 P.M. and 6:30 P.M., for a pain rating of 8-10.

The Blood Pressure and Respiratory Rate History did not indicate vitals signs were taken at 5:30 P.M.or 6:30 P.M.

The MAR indicated that the Duragesic Patch was applied to Patient #1 at 7:15 P.M.

The MAR indicated that Patient #1 received Morphine 5 mg IM at 7:30 P.M. for a pain rating of 10.

The MAR indicated that Patient #1 received his/her first dose of Flomax 0.4 mg by mouth at 8:00 P.M.

The Blood Pressure and Respiratory Rate History indicated that on 10/31/12 at 8:10 P.M., Patient #1's blood pressure was 140/90 with a respiratory rate of 22 breaths per minute.

The MAR indicated that Patient #1 received Morphine 5 mg IM at 8:30 P.M. and 9:30 P.M. for a pain rating of 9-10 as well as his/her regular scheduled medications.

The Blood Pressure and Respiratory Rate History indicated that on 10/31/12 at 9:30 P.M., Patient #1's blood pressure was 117/83 with a respiratory rate of 18 breaths per minute.

Surveyor #2 interviewed Nurse #1 on 12/10/12 at 2:35 P.M. Nurse #1 said that she was the Medication Nurse on the evening of 10/31/12. Nurse #1 said that she was responsible for before and after pain medication assessments. Nurse #1 said that Patient #1 was awake, alert and oriented each time she administered the Morphine.

The Nurses Notes, dated 10/31/12 at 11:00 P.M. and entered by Nurse #1, indicated that at 10:30 P.M., Patient #1's blood pressure was 64/46 and that she notified the charge nurse (Nurse #2). Nurse #1 said that Patient #1 was sleeping, but responded to verbal stimuli and reported no relief from the pain.

Surveyor #2 interviewed Nurse #2 on 12/10/12 at 2:44 P.M. Nurse #2 said she was the charge nurse on the evening of 10/31/12. Nurse #2 said that she called Physician #2 at 9:45 P.M. (after Patient #1 received 4 consecutive doses of hourly Morphine) concerning Patient #1's uncontrolled pain and Physician #2 ordered a one-time dose of Morphine 7.5 mg IM. Nurse # 2 said she called Physician #2 again at 10:30 P.M. about Patient #1's blood pressure of 64/46 and Physician #2 discontinued the Morphine. Nurse #2 said that Patient #1 was still responsive at the change of shift.

The Nurses Notes, dated 11/1/12 at 1:44 A.M. indicated that at 1:25 A.M., Patient #1 was found to be unresponsive with a blood pressure of 48/? (unable to hear diastolic [bottom] number) with a normal heart and respiratory rate. A Rapid Response (when a patient demonstrates clinical deterioration and summons in-house medical, nursing, and respiratory personnel) was called and the Physician was notified. The Notes indicated that the Duragesic patch was removed. Nursing notes did not indicate that Narcan (a narcotic reversal agent used as a first line drug in reversing low blood pressure and over sedation) was considered. Interviews with nurses on the Neuromuscular Unit indicated that they were aware Narcan was available, but had never used it before.

Surveyor #1 and Surveyor #2 interviewed Physician #2 in person on 12/11/12 at 8:43 A.M.
Physician #2 said that he was on call thru the night on 10/31/12 to 11/1/12. Physician #2 said that he was called about Patient #1's condition. Physician #2 said that he gave the order to remove the Duragesic Patch and transfer Patient #1 to the Acute Care Hospital. Physician #2 said that he had considered Narcan but did not give the order to administer it.

The Nurses Notes, dated 11/1/12 at 1:57 A.M. indicated that Patient #1 was transferred to an acute care hospital where Patient #1 received Narcan and IV fluids to stabilize his/her blood pressure and level of consciousness.

Surveyor #2 reviewed the Blood Pressure and Respiration History and the MAR regarding the administration times of Morphine for 10/31/12. Comparison of the the Blood Pressure and Respiration History and the MAR indicated that vitals were taken at 2:19 A.M., 11:00 A.M., 4 P.M., 8:10 P.M., 9:30 P.M. and 10:45 P.M. and not in accordance with the Pain Management Policy.

Surveyor #2 reviewed the Pain Assessment Documentation for 10/31/12. The documentation did not indicate that Patient #1's sedation level was assessed.

Surveyor #1 and Surveyor #2 interviewed the Medical Director on 12/11/12 at 11:16 A.M. The Medical Director said that the Flomax, in combination with the narcotics, may have contributed to Patient #1's condition as it can cause a lowering of the blood pressure.

Surveyor #2 interviewed the CNO on 12/11/11 at 1:30 P.M. The CNO said that the Pain Assessments were part of the electronic record and did not include an assessment of the sedation level. Narrative Nursing Notes did not indicate that a sedation level was assessed and documented on Patient #1 while receiving multiple doses of morphine.