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Based on review of records, staff interview, and policies and procedures the facility failed to ensure the patient rights for patient #1.

-Patient #1 was discharged with a pain level of ten on a scale of zero to ten;

- The nurse documented an allergy to IV contrast, no allergy band was placed on the patient and IV contrast was administered.

- The History and Physical for the surgical procedure on 9/24/12 was not available for review at the time of the survey.

Findings included:

Review of the clinical record for patient #1 revealed the nurse discharged the patient home on 9/24/12 at 1:52pm.

Review of the PACU Record dated 9/24/12 revealed the patient was discharged with a pain level of ten on a scale of zero to ten. In the section "PACU vital signs," that last documented pain assessment performed was at 12:31pm. The nurse documented the pain level as ten. In the section Discharge Evaluation from PACU, the nurse noted the vital signs were stable. In the section of the Nursing Diagnosis Evaluation, the nurse checked the patient verbalizes the pain was tolerable and comfort was maintained.

Review of physician post-operative orders dated 9/24/12 revealed a "pain scale 7-10: severe... vitals signs every 15 minutes until stable... discharge home when criteria met."

On 9/24/12 at 2:23pm and 2:31pm the patient was administered Dilaudid IV and was not observed per facility policies and procedures. The nursing documentation of observations were not available for review. The nurse last documented on the nurses notes at 1:10pm and the last vital signs taken were at 12:31pm. Facility policies and procedures stated that a patient who is administered a narcotic would be observed for at least 30 minutes and vital signs every 15 mintues for any adverse/allergic reactions. The facility failed to observe patient #1 after the administration of Dilaudid.

Review of the clinical record for patient #1 for 9/24/12 revealed patient #1 had an Endoscopic Retrograde Choleangiopancreatography (ERCP). The History and Physical for the surgical procedure performed on 9/24/12 was not available for review at the time of the survey.

Review of the Pre-operative Assessment dated 9/24/12 for patient #1 revealed the nursing staff failed to place an allergy wrist band on patient #1 who had a documented allergy to IV contrast and the patient was administered IV contrast in the operating room.

On 9/24/12, the Pre-op Admission form stated the patient had an allergy to IV contrast. In the section, "allergy band on," the nurse checked "No."

Review of facility document "Pain Procedure/Interventional Radiology/EGD Documentation Form dated 9/24/12 revealed the nurse documented in the Notes section "IV contrast <(less than) 10 ml, Saline <10 ml." The allergy section revealed the patient had an allergy to IV contrast. Patient #1 was administered IV contrast.

In an interview on 12/5/12 at 4/:15pm with the Chief Nursing Officer, she confirmed the practitioner failed to complete a History and Physical prior to surgery, the patient was discharged with a pain level of ten, the nursing staff administered Dilaudid and documentation regarding the interventions were not available for review, and the patient was discharged at 1:52pm with a pain level of ten.

The CNO stated the nursing staff and the practitioners did not follow facility policies and procedures.

Based on record review, staff interview, and policies and procedures, the facility failed to have a well organized nursing service.

- Patient #1, the patient was given Dilaudid on 9/24/12 at 2:23pm and 2:31pm and was discharged at 1:52pm.

- Patient #1 was discharged home with pain level of ten on a scale of zero to ten.

- The nurse documented an allergy to IV contrast, no allergy band was placed on the patient and IV contrast was administered.

Findings included:

Review of the Post Anesthesia Care Unit (PACU) Record dated 9/24/12, in the section "PACU vital signs" revealed the nurse noted that patient #1 had a pain level of ten on a scale of one to ten at 12:11pm, 12:16pm, 12:21pm, 12:26pm, and 12:31pm. There was no documentation in the Nurses' notes of interventions or the patient's response to the interventions.

Review of the PACU Record dated 9/24/12 revealed the patient's last three doses of pain medication were at 12:41pm (Morphine 1mg IV), 2:23pm (Dilaudid 0.5mg IV), and 2:31pm (Dilaudid 0.5mg IV). Documentation revealed the patient was discharged at 1:52pm.

Review of the PACU Record dated 9/24/12, in the nurse's notes revealed at 12:16pm the patient's pain level was a ten. There was no other documentation in the nurses' notes regarding the patient's pain management.

The patient was discharged with a pain level of ten on a scale of zero to ten. In the section "PACU vital signs," that last documented pain assessment was at 12:31pm. The nurse documented the pain level as ten. In the section Discharge Evaluation from PACU, the nurse noted the vital signs were stable. In the section of the Nursing Diagnosis Evaluation, the nurse checked the patient verbalizes the pain was tolerable and comfort was maintained.

Physician post-operative orders dated 9/24/12 revealed a "pain scale 7-10: severe... vitals signs every 15 minutes until stable... discharge home when criteria met."

Review of the Pre-op Nursing Assessment dated 9/24/12, the nurse documented the patient had an allergy to IV contrast. The nurse also noted on the section for "allergy band on" the nurse checked "No." The nurse noted "Yes" to allergies listed.

Review of facility document "Pain Procedure/Interventional Radiology/EGD Documentation Form" dated 9/24/12 revealed the nurse documented in the Notes section "IV contrast <(less than) 10 ml, Saline < 10 ml." The allergy section revealed the patient had an allergy to IV contrast. Patient #1 was administered IV contrast.

The nursing staff failed to place an allergy wrist band on patient #1 who had an allergy to IV contrast. The patient was administered IV contrast in the operating room.

Review of the 7/24/12 admission, the nurse documented the patient was allergic to Iodine. There was no documentation on the 9/24/12 Pre-op admission form of an Iodine allergy.

Review of the facility policy entitled "Admission Assessment and Reassessment of Patients-Nursing" stated, "Admission Assessment Policy: An initial Admission assessment is the initial nursing assessment that is done upon admitting the patient to Pine Creek Medical Center... Within 1 hour of the patient's arrival for the Day Surgery Unit. (sic) An initial assessment and documentation of vital signs, allergies, diagnosis, brief statement of patient condition or needs."

Review of "Reassessment Policy" stated "A reassessment is any assessment done after the initial assessment. Documentation of a patient's reassessment will be completed a minimum of every shift, or with changes in the patient's condition. Reassessment of a patient should reflect a review of ... any pertinent changes, patient's response to interventions, and who was notified."

Review of the Required Documentation revealed "Documentation will include: 2. All surgery patients will receive a preoperative and postoperative assessment by the Perioperative Nurses. This is documented on the intraoperative record. 3. Surgery patient patients are reassessed upon admission and at discharge from the Post Anesthesia Care Unit (PACU). This documentation will be on the patient care record upon patient's arrival to the Nursing Unit. 4. Reassessment will be completed by the nurse accepting the patient from PACU. It will include a written review of patient-specific data, any pertinent changes, the patient's response to interventions, and who was notified of a patient's change of condition. An assessment must be documented a minimum of once every shift."

Review of Facility policy entitled, "Admission to the PACU " stated, "3. The admitting PACU nurse will perform these tasks immediately: e. Measure and record the blood pressure and respirations. Report all vital signs to the anesthesiologist or attending physician. Record vital signs on the PACU record. 7. Assess pain status and medicate accordingly. 12. All observations and interventions should be recorded on the PACU record according to charting policy."

Review of Facility policy entitled "Verbal and Telephone orders" stated, "3. The telephone order must be documented by the professional who accepts the order and will include: a: Name of patient; b. Date; c. Time; d. Order: if medication name dose, frequency, route, quantity or duration; e. First and last name of physician issuing the order; g. Legal signature of health care professional receiving the order; and h. Read back and confirmed (RBAC) must follow each order."

In an interview with the Chief Nursing Officer on 12/5/12 at 4:15pm, she confirmed the nursing staff failed to reassess patient #1, discharged the patient with a pain level of ten and the nursing staff failed to follow the physician orders.

The CNO also stated the nursing staff failed to follow policies and procedures for Assessment/Reassessment, Documentation requirements, and the Verbal orders. She stated the facility would re-educate the staff on the facility's policies and procedures.

Based on staff interview and record review the facility failed to ensure the effective operation of the grievance process. As per facility policies and procedures, a family member called the facility and stated patient #1 was having post-operative complications and the facility failed to review and resolve the patient's grievance.

Findings included:

Review of the clinical record for patient #1 revealed the patient was discharged at 1:52pm.

Review of the PACU Record dated 9/24/12 revealed the patient's last three doses of pain medication were at 12:41pm (Morphine 1mg IV), 2:23pm (Dilaudid 0.5mg IV), and 2:31pm (Dilaudid 0.5mg IV).

Review of the PACU Record dated 9/24/12, in the nurse's notes revealed at 12:16pm the patient's pain level was a ten. There was no other documentation in the nurses' notes regarding the patient's pain management available for review.

Review of the Post Anesthesia Care Unit (PACU) Record dated 9/24/12, in the section "PACU vital signs" revealed the nurse noted that patient #1 had a pain level of ten on a scale of zero to ten at 12:11pm, 12:16pm, 12:21pm, 12:26pm, and 12:31pm. There was no documentation in the Nurses' notes of interventions or the patient's response to the interventions available for review.

In an interview on 12/5/12 at 4:15pm with the CNO, she recalled that she received a phone call on 9/24/12 from a family member regarding patient #1. The family member had expressed their concerns regarding the surgery. She recalled the family member stated that the patient was having surgical problems and wanted to speak with the surgeon. Tho CNO referred the family member to the surgeon. She stated that the facility failed to generate a grievance because the family member was calling to speak with the surgeon and. The CNO stated the facility failed to follow up on the phone call placed by the family member. The surveyor asked the CNO, "I want to make sure I understand correctly, a family member called your facility to state that their loved one, a 95 year old patient, who was having complications from a surgery performed in your facility, and your facility failed make a follow up phone call regarding her concerns? The CNO replied the facility did not consider the call a grievance because the family member called for the surgeon. She stated she initially did not believe the call was a grievance but after reviewing the policy she confirmed the facility failed to review and resolve the patient's grievance.

Facility policy entitled "Patient Rights and Responsibility" states, "At Pine Creek Medical Center all patients have the right to: Express dissatisfaction with care or treatment at any time and to receive a response to the complaint."

Facility policy entitled "Patient Grievance Policy" stated "Definition: Patient Grievance is a formal or informal written or verbal complaint that is made to the hospital by a patient (or their representative) when a patient issue cannot be resolved promptly by the staff present, or the complaint is referred to the department manager, Patient Safety Officer or Hospital Administrator is considered a grievance."

"Examples: An unresolved issue communicated to the hospital about care or services, after the patient was discharged."

"Grievance Process: 5. Quality manager refers the complaint to the Administrator and or Medical Executive Committee as appropriate. 6. A written response is given to the complainant within 72 hours after the review is completed. 7. All patient grievances are discussed in the Performance Improvement Committee and reviewed by the Medical Executive Committee."

Based on record review and staff interview, the facility failed to provide care in a safe setting and pain management for patient #1.

- The History and Physical was not completed prior to surgery.

- Reassessments after pain medication are administered were not performed.

- Patient #1 was discharged with a pain level of ten on a scale of zero to ten.

Findings included:

Review of the clinical record for patient #1 revealed that on 9/24/12 there was no history and physical completed prior to the surgical procedure Endoscopic Retrograde Cholangiopancreatography (ERCP) performed.

Medical Staff Bylaws and Regulations stated History and Physical's must be completed prior to surgery.

Review of the Post Anesthesia Care Unit (PACU) Record dated 9/24/12, on the PACU vital signs revealed the nurse noted the patient #1 had a pain level of one on a scale of zero to ten at 12:11pm, 12:16pm, 12:21pm, 12:26pm, and12:31pm. There was no documentation the nurse reassessed the patients pain level. The nursing staff failed to supervise and evaluate the care for patient #1. Physician's post-operative orders revealed a pain level of seven-ten was "severe."

Review of the PACU Record dated 9/24/12 revealed the patient last three doses of pain medication were at 12:41pm (Morphine 1mg IV), 2:23pm (Dilaudid 0.5mg IV), and 2:31pm (Dilaudid 0.5mg IV).

On 9/24/12 at 2:23pm and 2:31pm the patient was administered Dilaudid IV and was not observed per facility policies and procedures. The nursing documentation of observations were not available for review. The nurse last documented on the nurses notes at 1:10pm and the last vital signs taken were at 12:31pm. Facility policies and procedures stated that a patient who is administered a narcotic would be observed for at least 30 minutes and vital signs every 15 mintues for any adverse/allergic reactions. The facility failed to observe patient #1 after the administration of Dilaudid.

Review of the clinical record for patient #1 revealed the nurse discharged the patient home on 9/24/12 at 1:52pm.

Review of the PACU Record dated 9/24/12 revealed the patient was discharged with a pain level of ten on a scale of zero to ten. In the section "PACU vital signs," that last documented pain assessment performed was at 12:31pm. The nurse documented the pain level as ten. In the section Discharge Evaluation from PACU, the nurse noted the vital signs were stable. In the section of the Nursing Diagnosis Evaluation, the nurse checked the patient verbalizes the pain was tolerable and comfort was maintained.

Review of physician post-operative orders dated 9/24/12 revealed a "pain scale 7-10: severe... vitals signs every 15 minutes until stable... discharge home when criteria met."

Review of the Pre-op Nursing Assessment dated 9/24/12, the nurse documented the patient had an allergy to IV contrast. The nurse also noted on the section for the allergy band on "No." The nurse noted "Yes" to allergies listed.

Review of facility document "Pain Procedure/Interventional Radiology/EGD Documentation Form" dated 9/24/12 revealed the nurse documented in the notes section "IV contrast <(less than) 10 ml, Saline <10 ml." The allergy section revealed the patient had an allergy to IV contrast. Patient #1 was administered IV contrast.

Facility policy entitled "Patient Rights and Responsibility" states, "At Pine Creek Medical Center all patients have the right to: Considerate and respectful care; Safe Care; Timely and Effective Pain Management."

In an interview with the Chief Nursing Officer on 12/15/12 at 4:15pm, she confirmed there was no history and physical for the surgical procedure performed on 9/24/12 in the clinical record for patient #1. The CNO also confirmed the nursing staff failed to reassess patient #1, as well as place an allergy band on patient #1.

Based on record review and staff interviews, and policies and procedures, the facility failed to ensure a completed History and Physical was in clinical record of patient #1 prior surgical procedure.

- Patient #1 had a surgical procedure on 9/24/12 which required anesthesia services, and the History and Physical was not available for review at the time of the survey.

Findings included:

Review of the clinical record for patient #1 revealed that on 9/24/12 the history and physical was not completed prior to the surgical procedure Endoscopic Retrograde Cholangiopancreatography (ERCP) performed. The history and physical was not available for review at the time of the survey.

Review of Medical Staff Bylaws and Regulations, last revised February 2, 2011, stated "4.4 History and Physical Prior to Surgery: A medical history and physical examination needs to be completed for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services." "If the history and physical information and preanesthesia evaluation have not been recorded in the medical recorded before the posted time of the procedure the patient will not be transferred to the surgery site. If not recorded the procedure will be cancelled."

Review of facility policy entitled "Documentation required for surgical case" stated, "Procedure: All preoperative information needed must be on the patient's medical record prior to his/her admission to the surgical suite. This includes, but is not limited to: c. A recent history and physical."

In an interview with the Chief Nursing Officer on 12/5/12 at 4:15pm, she confirmed the clinical record of patient #1 failed to have a completed History and Physical for the surgery date of 9/24/12 available for review.

Based on record review, staff interview, and policies and procedures, the facility failed to have a well organized nursing service.

- Patient #1, the patient was given Dilaudid on 9/24/12 at 2:23pm and 2:31pm and was discharged at 1:52pm.

- Patient #1 was discharged home with pain level of ten on a scale of zero to ten.

- The nurse documented an allergy to IV contrast, no allergy band was placed on the patient and IV contrast was administered.

Findings included:

Review of the Post Anesthesia Care Unit (PACU) Record dated 9/24/12, in the section "PACU vital signs" revealed the nurse noted that patient #1 had a pain level of ten on a scale of one to ten at 12:11pm, 12:16pm, 12:21pm, 12:26pm, and 12:31pm. There was no documentation in the Nurses' notes of interventions or the patient's response to the interventions.

Review of the PACU Record dated 9/24/12 revealed the patient's last three doses of pain medication were at 12:41pm (Morphine 1mg IV), 2:23pm (Dilaudid 0.5mg IV), and 2:31pm (Dilaudid 0.5mg IV). Documentation revealed the patient was discharged at 1:52pm.

Review of the PACU Record dated 9/24/12, in the nurse's notes revealed at 12:16pm the patient's pain level was a ten. There was no other documentation in the nurses' notes regarding the patient's pain management.

Review of the PACU Record revealed the patient was discharged with a pain level of ten on a scale of zero to ten. In the section "PACU vital signs," that last documented pain assessment was at 12:31pm. The nurse documented the pain level as ten. In the section Discharge Evaluation from PACU, the nurse noted the vital signs were stable. In the section of the Nursing Diagnosis Evaluation, the nurse checked the patient verbalizes the pain was tolerable and comfort was maintained.

Physician post-operative orders dated 9/24/12 revealed a "pain scale 7-10: severe... vitals signs every 15 minutes until stable... discharge home when criteria met."

Review of the Pre-op Nursing Assessment dated 9/24/12, the nurse documented the patient had an allergy to IV contrast. The nurse also noted on the section for "allergy band on" the nurse checked "No." The nurse noted "Yes" to allergies listed.

Review of facility document "Pain Procedure/Interventional Radiology/EGD Documentation Form" dated 9/24/12 revealed the nurse documented in the Notes section "IV contrast <(less than) 10 ml, Saline < 10 ml." The allergy section revealed the patient had an allergy to IV contrast. Patient #1 was administered IV contrast.

The nursing staff failed to place an allergy wrist band on patient #1 who had an allergy to IV contrast. The patient was administered IV contrast in the operating room.

Review of the facility policy entitled "Admission Assessment and Reassessment of Patients-Nursing" stated, "Admission Assessment Policy: An initial Admission assessment is the initial nursing assessment that is done upon admitting the patient to Pine Creek Medical Center... Within 1 hour of the patient's arrival for the Day Surgery Unit. (sic) An initial assessment and documentation of vital signs, allergies, diagnosis, brief statement of patient condition or needs."

Review of "Reassessment Policy" stated "A reassessment is any assessment done after the initial assessment. Documentation of a patient's reassessment will be completed a minimum of every shift, or with changes in the patient's condition. Reassessment of a patient should reflect a review of ... any pertinent changes, patient's response to interventions, and who was notified."

Review of the Required Documentation revealed "Documentation will include: 2. All surgery patients will receive a preoperative and postoperative assessment by the Perioperative Nurses. This is documented on the intraoperative record. 3. Surgery patient patients are reassessed upon admission and at discharge from the Post Anesthesia Care Unit (PACU). This documentation will be on the patient care record upon patient's arrival to the Nursing Unit. 4. Reassessment will be completed by the nurse accepting the patient from PACU. It will include a written review of patient-specific data, any pertinent changes, the patient's response to interventions, and who was notified of a patient's change of condition. An assessment must be documented a minimum of once every shift."

Review of Facility policy entitled, "Admission to the PACU " stated, "3. The admitting PACU nurse will perform these tasks immediately: e. Measure and record the blood pressure and respirations. Report all vital signs to the anesthesiologist or attending physician. Record vital signs on the PACU record. 7. Assess pain status and medicate accordingly. 12. All observations and interventions should be recorded on the PACU record according to charting policy."

Review of Facility policy entitled "Verbal and Telephone orders" stated, "3. The telephone order must be documented by the professional who accepts the order and will include: a: Name of patient; b. Date; c. Time; d. Order: if medication name dose, frequency, route, quantity or duration; e. First and last name of physician issuing the order; g. Legal signature of health care professional receiving the order; and h. Read back and confirmed (RBAC) must follow each order."

In an interview with the Chief Nursing Officer on 12/5/12 at 4:15pm, she confirmed the nursing staff failed to reassess patient #1, discharged the patient with a pain level of ten and the nursing staff failed to follow the physician orders.

The CNO also stated the nursing staff failed to follow policies and procedures for Assessment/Reassessment, Documentation requirements, and the Verbal orders. She stated the facility would re-educate the staff on the facility's policies and procedures.

Based on record review and staff interview, the nursing staff failed to ensure that the discharge requirements for patient #1 were met. Patient #1 was discharged on 9/24/12 at 1:52pm with a pain level of ten on a scale of zero to ten.

Findings included:

Review of the clinical record for Patient #1 revealed the patient was discharged on 9/24/12 at 1:52pm with a pain level of ten.

Review of the PACU Record revealed the patient was discharged with a pain level of ten on a scale of zero to ten. In the section "PACU vital signs," that last documented pain assessment was at 12:31pm. The nurse documented the pain level as ten. In the section Discharge Evaluation from PACU, the nurse noted the vital signs were stable. In the section of the Nursing Diagnosis Evaluation, the nurse checked the patient verbalizes the pain was tolerable and comfort was maintained.

Review of physician post-operative orders dated 9/24/12 revealed "Pain scale: 1-3 mild; 4-6 moderate; 7-10 severe ...V/S (vital signs) q(every) 15 minutes until stable ... Discharge home when criteria met..."

Review of the Post Anesthesia Care Unit (PACU) Record dated 9/24/12, in the section, the PACU vital signs revealed the nurse noted that patient #1 had a pain level of ten on a scale of one to ten at 12:11pm, 12:16pm, 12:21pm, 12:26pm, and 12:31pm. There was no documentation in the Nurses' notes of interventions or the patient's response to the interventions available for review.

Review of the PACU Record dated 9/24/12 revealed the patient's last three doses of pain medication were at 12:41pm (Morphine 1mg IV), 2:23pm (Dilaudid 0.5mg IV), and 2:31pm (Dilaudid 0.5mg IV).

Review of the Facility policy entitled "Discharge of Patients after Medication in PACU" stated, "It is the policy of Pine Creek Medical Center to observe any patient for thirty (30) minutes after the administration of antibiotics or narcotic medications for a possible adverse/allergic reaction." The procedure stated "After the patient receives their last dose of antibiotics or narcotic medication they will remain in PACU for at least 30 minutes in order for the nurse to monitor for any possible adverse/allergic reactions. During this time the patient will continue to have their vital signs checked at least every 15 minutes."

In an interview with the Chief Nursing Officer on 12/5/12 at 4:15pm, she confirmed there was no documentation for review that the nursing staff observed patient #1 after the administration of narcotics and discharged the patient with a pain level of ten. The CNO confirmed the nursing staff failed to follow facility policies and procedures and should not have discharged the patient with a pain level ten.