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Based on observation, interview and record reviews the hospital failed to follow the policy and procedure for pain management as evidenced by: a) patients not being assessed for pain every two hours (Patient #4, #5); b) patients not being reassessed for pain after administration of pain medication (Patient #3, #10), and c) physicians not notified in a timely manner of inadequate relief of pain or family refusal to allow a patient to receive certain pain medications (Patient #4) for 3 of 10 patients and/or medical records reviewed. Findings:

a) patients not being assessed for pain every two hours
Patient #4
Review of the consumer Patient #4's medical record revealed he was a 64 year old male who had been admitted to the hospital on 01/19/10 for chronic respiratory failure (ventilator dependent) with a history of MI (Myocardial Infarction), ACID (Automated Cardiac Internal Defibrillator), severe COPD (Chronic Obstructive Pulmonary Disease), Severe Hypoxemia, Non-Hodgkin's Lymphoma, Partial Gastrectomy, Complete AV Block, Compression Fracture to spine (2 cervical and 3 lumbar surgeries), A-fib (Atrial Fibrillation), Anemia and Sacral Decubiti. Further review revealed Patient #4 had a Foley catheter, fecal bag and a NG (naso-gastric) tube.

Review of the nursing notes for Patient #4 revealed pain had not been assessed as follows: 01/20/10 from 3:00pm through 7:00pm; 01/21/10 from 4:00pm through 7:00pm; 01/23/10 4:00pm through 8:00pm; 01/24/10 1:00am through 7:00am; 01/24/10 from 11:00am through 7:00pm and 11:00pm through 7:00am (01/25/10) and 1/26/10 2:00am through 07:00am.

Patient #5
Review of the medical record for Patient #5 revealed she had been admitted on 12/22/09 for treatment of decubitus ulcers.

Review of the nurses notes for Patient #5 revealed pain had not been assessed as follows:
12/24/09 4:00pm through 12 midnight; 01/18/10 7:00am through 7:00pm; and 01/19/10 7:00am through 7:00pm.

Review of policy #108 titled "Pain, Assessment and Documentation" last revised August 2000, revealed.... "III. Procedure: A. Pain, assessment and documentation will become the 5th vital sign...."


b) patients not being reassessed for pain after administration of pain medication
Review of the medical record for Patient #3 revealed she had been admitted to the hospital on 03/25/10 for treatment of a Stage IV decubitus ulcer and to rule out gangrene.

Review of the nurses' noted dated 03/25/10 revealed Patient #3 had been assessed for pain at 0610 (6:00am 03/26/10) and Percocet 2 tablets po (by mouth) had been administered as per MD order for moderate pain. Further review of the nurses' notes revealed no documented evidence #3 had been reassessed for pain.

Review of the medical record for Patient #10 revealed she was a 104 year old who admitted to the hospital with diagnosis that included urinary tract infection, sepsis, dementia and debility.

An observation was made on 3/29/10 at 1:10 PM of Patient #10 sitting up in bed and being fed a pureed diet for lunch by S6, RN. Further observation revealed #10 to be grimacing and complaining of pain. During an interview with Patient #10 at this time, she was able to correctly state her last name and added she wanted to get out of bed.

In interview with S6,RN on 3/29/10 at 1:10 PM, he indicated Patient #10 was 104 years old who was admitted to the hospital for altered mental status and uncontrolled pain. He reported Patient #10 was on room air and had an IV infusing at 50 milliliters per hour. S6, RN indicated he made rounds on Patient #10 every 2 hours and added she had been drowsy earlier in the morning. He confirmed that she was grimacing and complaining of pain during this interview. S6, RN also reported that he had not administered any pain medication to Patient #10 during his shift.

An observation was made of Patient #10 at 2:25 PM on 3/29/10. She was laying in bed with the head of the bed elevated, was dozing but was easily aroused. Patient #10 stated that she wanted to get out of bed.

Review of physician orders for Patient #10 written on 3/28/10 at 10:11 PM revealed Darvocet 1 PO (orally) every 6 hours PRN (as needed) for pain.

Review of the Medication Administration Record (MAR) for 3/29/10 through 3/30/10 revealed an entry dated 3/28/10 at 1:15 PM by S6, RN that Darvocet 1 PO Q6PRN Pain had been administered to Patient #10. Review of the nurse's notes written by S6, RN revealed he had administered Darvocet 1 tablet PO for pain to Patient #10 at 1:15 PM. Further review of the documentation revealed patient #10 had a pain scale of 8 out of 10 at 1:00 PM.

An interview was held with S8, RN on 2/29/10 at 2:30 PM. She indicated the documentation revealed Patient #10 had received Darvocet 1 tablet at 1:15 PM for a pain rated as 8 out of 10 on the pain scale. S8, RN reported she ws unable to find documentation in the medical record that Patient #10 had been reassessed following the administration of Darvocet for pain.

An interview was held with S6, RN on 3/29/10 at 2:35 PM, which was one hour and twenty minutes after Patient #10 was administered Darvocet for pain of 8 out of 10 on the pain scale. S6, RN indicated he reassess a patient 1 hour after he administers oral pain medication. After review of the medical record for Patient #10, S6,RN indicated he had not reassessed this 104 year old patient after an oral Darvocet had been administered for pain of 8 out of 10 on the pain scale.

In a face to face interview on 03/29/10 at 10:00am S1- RN Director of Nursing indicated assessments should have been done after the administration of pain medication to determine its effectiveness.

Review of policy #108 titled "Pain, Assessment anad Documentation" last reviewed August 2000, revealed.... "Procedure: G. After administration of pain medication the patient shall be assessed at least 5-15 minutes following epidural and IV (Intravenous) administration of pain medication and 30-60 minutes following po (by mouth), subcutaneous, intramuscular and transdermal administration and after medication is given and until there is relief...."


c) physicians not notified in a timely manner of inadequate relief of pain or family refusal to allow a patient to receive certain pain medications

Review of the consumer Patient #4's medical record revealed he was a 64 year old male who had been admitted to the hospital on 01/19/10 for chronic respiratory failure (ventilator dependent) with a history of MI (Myocardial Infarction), ACID (Automated Cardiac Internal Defibrillator), severe COPD (Chronic Obstructive Pulmonary Disease), Severe Hypoxemia, Non-Hodgkin's Lymphoma, Partial Gastrectomy, Complete AV Block, Compression Fracture to spine (2 cervical and 3 lumbar surgeries), A-fib (Atrial Fibrillation), Anemia and Sacral Decubiti. Further review revealed Patient #4 had a Foley catheter, fecal bag and a NG (naso-gastric) tube.

Review of the Admission Orders for Patient #4 dated 01/19/10 revealed an order for the following pain medications: Hydrocodone 7.5/75 i tablet po (by mouth) every 6 hours and a Fentanyl patch 50 meq every 72 hours.

Review of the Initial Assessment for Patient #4 revealed no documented evidence the Fentanyl patch was on the patient at the time of admit.

Review of the MAR (Medication Administration Record) for #4 revealed Fentanyl patch was due to be given 01/21/10 @1800; however the time of 1800 was circled as not given. Review of the nursing notes dated 01/21/10 revealed no documented evidence as to why the medication had not been given. An entry dated 01/22/10 @ 1900 revealed the family had requested that Fentanyl be listed as an allergy. Further review revealed no documented evidence the reason for the request or that the physician had been notified. Review of the MAR dated 03/21/10 revealed the Fentanyl still had not been given.

In a telephone interview on 03/31/10 at 11:30am S12 RN indicated S16, Patient #4's wife asked her to step out of the patient's room and told S12 her husband was allergic to Fentanyl and did not want it to be given; however S16 could not tell her what type of reaction her husband had with the Fentanyl. S16 indicated to RNS12 that she wanted the Ativan discontinued because it was not helping and also wanted the Vicodin given every 4 hours instead of every 6 hours as had been ordered by the physician. S12 indicated she did not notify the MD because it was late so she reported the information to the oncoming nurse. After review of the chart she verified nothing had been documented concerning notification of the physician and that changes in the medication regime did not occur until 01/25/10.