HospitalInspections.org

Based on record review and interview, the facility failed to meet the right of the patient to the hospital's reasonable response to his requests and needs for pain medication, in that the physician had told the patient he would be ordered a PCA (Patient Controlled Analgesic) to help control his post-operative pain.

Findings include:

1. When the patient arrived to the inpatient floor, he did not have orders for a PCA for postoperative pain control. For the time period of 1750 on 9/19/2016 to 3:55 on 9/20/2016 (8 hours), the patient was given oral oxycodone for his post operative pain. The patient's pain level ranged from 10 to 7 during this time period. The PCA order was found in the back of the chart and the PCA was started at 355 AM on 9/20/2016.

2. An interview with Personnel #5 on 6/21/2017 at 2:50 PM, Personnel #5 stated that the nurses did not find a PCA order in the chart and when reconciling the patient's medication record there was no PCA orders. The order for the PCA was found in the back of the chart and 8 hours later the patient received the PCA pain medication.

3. No incident report was completed regarding this missed medication order. No complaint was received regarding this incident of missed medication order.