HospitalInspections.org

Based on observation, interview and record review, the facility failed to ensure:
1. Their nursing staff adhered to the policy & procedure (P&P) for "Pain Management Plan" by not documenting proper pain reassessment for two of 30 sampled patients (Patients 22 and Patient 29).?
This deficient practice had the potential to result in ineffective pain management.?

2. The nursing staff adhered to the facility's policy & procedure (P&P) for "Administration of Medications via Injection" and the facility's guidelines for "Intravenous Tubing (IV tubing - a thin, flexible plastic tube used to give fluids and medications directly into a patient's bloodstream) Management", when the facility failed to change a past due IV tubing infusing medication and accurately document management of the IV tubing for one of 30 sampled patients (Patient 2).?
This deficient practice had the potential to result in the risk for bacteremia (bloodstream infection) potentially leading to sepsis (a life-threatening blood infection). ?
Findings:
1.
A. During a review of Patient 22's "History & Physical" (H&P - a formal and complete assessment of the patient and problem), the H&P indicated Patient 22 was admitted to the hospital on 5/4/2025 for acute hypoxemic respiratory failure (when the lungs cannot deliver enough oxygen to the blood and tissues), bilateral pneumonia (an infection/inflammation in both of the lungs), and dysphagia (difficulty swallowing). Patient 22 also had a tracheostomy tube (a tube placed in the neck to help the patient breathe better) and a percutaneous endoscopic gastronomy tube (PEG tube - a feeding tube placed directly in the abdomen).

During an interview with the Director of Nursing/Clinical Services (DNCS) on 5/28/2025 at 10:35 a.m., the DNCS stated if medication was given as an intervention (action taken) for pain, then the patient's pain should be reassessed (to consider something again) within one hour if given orally or through a feeding tube and within 30 minutes if the pain medication was given intravenously (IV - through the veins). The DNCS further stated it was important to reassess pain to ensure that the pain medication worked, or to try something else if it did not work.

During a concurrent interview and record review on 5/28/2025 at 1:18 p.m. with the DNCS, Patient 22's "Medication Administration Record" (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a patient) was reviewed. The MAR indicated Patient 22 had an order for 1000 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount) of acetaminophen (a pain medication also known as Tylenol) to be given every 6 hours PRN (as needed or requested by the patient) through the PEG tube for a reported pain intensity of five to six on the numeric pain scale (a method of measuring pain intensity by asking a patient to rate their pain on a scale from zero, which is no pain, to 10, which is the worst possible pain). The MAR further indicated that on 5/6/2025 at 5:46 p.m., Patient 22 received 1000 mg of acetaminophen through their PEG tube after reporting a pain intensity of five out of 10. There was no documentation that Patient 22's pain was reassessed after the administration of acetaminophen. The DNCS confirmed that there was no pain reassessment documented, as the MAR should indicate whether the administration was "effective" (successful) or "not effective" within one hour and it did not.

During a review of the facility's P&P titled "CORE: Pain Management Plan," dated 6/2023, the P&P indicated, "Pain is assessed at least every shift during regular shift assessments, with patient complaint of pain, as needed related to patient's treatment(s)/patient conditions, after analgesic [medications that relieve pain] administration and other pain interventions ... Reassessment of pain relief interventions vary according to patient level of pain and patient status, pain relief interventions performed by the nurse and/or pharmacological agent [medication] administered and route of administration, nursing judgment and according to physician orders if present.
1. Recommended timeframes for reassessment of effective of pain relief may include:
a. 30 minute reassessment - IM [intramuscular - through the muscle] injection and IV medication
b. 1 hour reassessment - oral medication and non-pharmacological [non-medication] interventions"

b. During a review of Patient 29's H&P dated 5/7/2025 at 3:19 p.m., the H&P indicated Patient 29 was admitted to the facility on 5/6/2025 for metastatic colon cancer (when the cancer spread from the colon to other parts of the body), several bowel obstructions (blockages in the small or large intestine), and aspiration pneumonia (a type of lung infection that occurs when something other than air, such as food, liquid, or saliva, is inhaled into the lungs).

During an interview with the DNCS on 5/28/2025 at 10:35 a.m., the DNCS stated if medication was given as an intervention for pain, then the patient's pain should be reassessed within 1 hour if given orally or through a feeding tube and within 30 minutes if the pain medication was given IV. The DNCS further stated it was important to reassess pain to ensure that the pain medication worked, or to try something else if it did not work.

During a concurrent interview and record review on 5/28/2025 at 2:17 p.m. with the DNCS, Patient 29's MAR was reviewed. The MAR indicated Patient 29 had an order for 0.5 mg of hydromorphone (a strong pain medication) to be given through the IV every three hours PRN for breakthrough pain (a sudden increase in pain that might occur in patients already in chronic pain, such as from cancer). The MAR also indicated:
1. Patient 29 received 0.5 mg of hydromorphone IV on 5/12/2025 at 9:52 p.m. for a pain intensity of nine out of 10. Patient 29's pain was reassessed as "somewhat effective" on 5/13/2025 at 2:40 a.m., four hours and 48 minutes later.
2. Patient 29 received 0.5 mg of hydromorphone IV on 5/13/2025 at 11:13 p.m. for a pain intensity of nine out of 10. Patient 29's pain was reassessed as "effective" on 5/14/2025 at 4:54 a.m., five hours and 41 minutes later.
The DNCS confirmed that Patient 29's pain should have been reassessed within 30 minutes.

During a review of the facility's P&P titled "CORE: Pain Management Plan," dated 6/2023, the P&P indicated, "Pain is assessed at least every shift during regular shift assessments, with patient complaint of pain, as needed related to patient's treatment(s)/patient conditions, after analgesic administration and other pain interventions ... Reassessment of pain relief interventions vary according to patient level of pain and patient status, pain relief interventions performed by the nurse and/or pharmacological agent administered and route of administration, nursing judgment and according to physician orders if present.
1. Recommended timeframes for reassessment of effective of pain relief may include:
a. 30 minute reassessment - IM(Intramuscular) injection (medication delivered directly in the muscle) and IV medication
b. 1 hour reassessment - oral medication and non-pharmacological interventions"


2.
During a review of Patient 2's "History & Physical" (H&P, a formal and complete assessment of the patient and the problem), dated 5/21/2025 at 12:00 a.m., the H&P indicated Patient 2 was admitted to the facility on 5/21/2025 for intracranial hemorrhage (bleeding within the skull), stroke (damage to the brain from lack of blood supply), respiratory failure (lungs cannot get enough oxygen into the blood), sepsis, and pneumonia (an infection/inflammation in the lungs).
During an observation on 5/27/2025 (Tuesday) at 2:38 p.m., of the Intensive Care Unit (ICU - a specialized hospital unit to provide critical care for patients' with severe, potentially life-threatening illnesses or injuries), Patient 2's IV tubing, infusing Precedex (dexmedetomidine - a medication used for sedation [a state of calmness, relaxation, or sleepiness]) via an IV Pump (a medical device that delivers medication/fluid into a patient's body in controlled amounts), was observed with a brightly colored, "change Monday" sticker attached to the IV tubing. The attachment contained a handwritten change (due) date of 5/26/2025. There is no time or initials indicated.
During a concurrent observation and interview with RN1 on 5/27/2025 at 2:41 p.m., RN1 stated, "I know! I am about to change my Precedex now". RN1 confirms being the assigned nurse for Patient 2. RN1 acknowledged observation of the handwritten date 5/26/2025 on the "Change Monday", brightly colored sticker attached to the IV tubing. RN1 stated Precedex IV tubing should be changed daily/every 24 hours. RN1 stated the importance of changing the IV tubing is for infection control prevention. RN1 reports being trained by the facility on IV tubing change recommendations/requirements and is aware of the facility's protocol.

During an interview with the Infection Control Preventionist (ICP) on 5/29/2025 at 2:09 p.m., ICP stated the handwritten date on the stickers placed on the IV tubing indicates the date the tubing is required to be changed. ICP stated the importance of changing the IV tubing is to prevent a Central Line-Associated Bloodstream Infection (CLABSI - a serious infection that enters the bloodstream through a catheter [a tube to deliver fluids/medicines into the body] placed in a large vein [ a blood vessel that carries blood towards the heart]). ICP stated most CLABSI comes from not appropriately changing the IV tubing.

During an interview with the Director of Nursing (DON)/Clinical Services (DNCS) on 5/29/2025 at 1:42 p.m., DNCS stated all nurses are required to complete training on IV tubing maintenance. DNCS stated completion of this training is required at start and annually during skills training/competencies. DNCS stated there is "No specific facility policy for IV tubing changes"; however, the facility uses a guideline/protocol that staff are provided training for and is placed in all medication work areas. An individual copy is provided to staff during their competency trainings. DNCS stated the guideline is reviewed and approved in collaboration with pharmacy standards. DNCS stated the guidelines are visibly placed/hanging in all medication rooms and nursing stations. DCNS stated the manually placed stickers on the IV tubing are color coordinated by days and allows easier visibility for staff to determine when a tubing change is required. DCNS stated the stickers contain the wording "change" with a specific day of the week, ranging from "Sunday to Saturday". The stickers are color coordinated (a different color for each day of the week) and applied to the IV tubing at the start of use. The sticker includes an area for the nurse to handwrite the date, time, and their initials. The required change date should be specific to the day of the week printed on the sticker. Per DNCS, medications differ on their tubing change requirements. The guideline helps to serve as a reminder of the tubing change requirements specific to different medication types. DCNS stated management for Precedex administration should be documented in the medication administration record (MAR - a drug chart to document all medications administered to a patient) and on the "Controlled Substance/Sedative Infusion Flowsheet" (paper sheet used to document specific medication administration and monitoring of the patient). DCNS states the documented administration details on both forms should accurately represent factual administration details.

During a record review of the facility's "untitled" and "undated" IV tubing guidelines, indicated "The sticker should reflect the day you are going to change the tubing! Not the day you hang the tubing". The guideline indicates to document the date & time the tubing is hung, with initials. The guideline indicates to also document the date and time to change the tubing. An example explaining, "If hung Friday, sticker is Saturday for Intravenous Piggyback (IVPB, a method of administering IV medications by connecting a small bag of medication [the piggyback] to an existing IV line, allowing two different IV fluids/medications at the same time) with a "change Saturday" pictured sticker sample. The guideline provides different IV solution types with the recommended IV tubing change. Precedex indicates to change the IV tubing every 24 hours.

During a record review of Patient 2's "Medication Administration Record" (MAR), undated, on 5/28/2025 at 4:29 p.m., the MAR indicates a Precedex IV solution bag was changed on 5/26/2025 at 6:00 a.m. and 10:00 p.m. There are no documented IV tubing changes. The MAR indicates a Precedex IV solution bag was changed on 5/27/2025 at 6:00 a.m., 2:57 p.m., and 10:00 p.m. An IV tubing change is documented at 2:57 p.m.

During a record review of Patient 2's "Controlled Substance/Sedation Infusion Flowsheet", undated, on 5/28/2025 at 4:16 p.m., the flowsheet indicates a new Precedex IV solution bag was hung on 5/26/2025 at 6:00 a.m., 2:00 p.m., and 10:00 p.m. The flowsheet documents an IV tubing change on 5/26/2025 at 2:00 p.m. The flowsheet indicates a new Precedex IV solution bag was hung on 5/27/2025 at 6:00 a.m., 2:00 p.m., and 10:00 p.m. The flowsheet documents an IV tubing change on 5/27/2025 at 2:00 p.m.

During a record review of the facility's policy and procedure (P&P), titled "CORE: Administration of Medications via Injection", dated 06/2022 (original date 01/2007), the P&P (page 1 of 7), section 3.a. indicates the individual administering the medication(s) must document all medications after administration in the patient's medical record.