HospitalInspections.org

Based on review of facility policy and procedures, review of medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure approved procedures were followed for documentation for the monitoring and assessment for patients receiving patient-controlled analgesia (PCA) for three of four medical records reviewed (MR1, MR5, MR7).

Findings include:
Review on January 19, 2018, of facility policy "Medications, Administration of: Patient-Controlled Analgesia," approved January 16, 2018, revealed "VII. Documentation: 1. Two (2) RNs/CRNAs are to independently verify and comments: a. Pump settings b. bag labeling for correct solution and concentration c. amount of fluid remaining in bag 2. Two RNs/CRNAs are to verify independently and document the above: a. At initiation of therapy. b with any change in prescription /order c. with every bag change d. Every change of primary nurse ... 3. The infusion bag is to be changed every 24 hours ... b. 2 RNs/CRNAs are to check and document infusion bag changes and fluid volume discarded on the paper Pain Management Flow Sheet/electronic MAR/flow sheet according to the Patient Care Manual, Medication Administration: Narcotic Controlled Substances procedure ... 5. For IV (intravenous) PCA Assess and document: ... B. respiratory rate, depth and level of sedation (1) every 15 minutes x 4 (2) every 30 minutes x 2 (3) every 4 hours except for patients who require more frequent vital sign assessment for other clinical issues ... X. Evidence Summary ... Patients utilizing a PCA pump should be monitored on a standardized assessment documentation system a minimum of every 4 hours ... Monitor & access patients at rest/during sleep ... ".
1) Review on February 2, 2018, of MR1 revealed an order for pain medication, Dilaudid, via patient controlled analgesia (PCA) pump on September 21, 2017, at 12:08 PM and initiated at 13:54 (1:54 PM). Further review of nursing documentation for MR1 revealed there was no documentation that the respiratory rate and depth and level of sedation were assessed and documented every 15 minutes x 4 and every 30 minutes x 2 as required by facility policy for the initiation of PCA on September 21, 2017.
Continued review of nursing documentation for MR1 revealed no documentation of vital signs every 4 hours on September 20, 2017, between 23:43 (11:43 PM) through 9:19 AM on September 21, 2017, and no documentation of vital signs on September 21, 2017, between 22:58 (10:58 PM) through 11:29 AM on September 22, 2017, and no documentation of vital signs between 11:29 AM through 16:10 (4:10 PM) on September 22, 2017.
Further review on February 2, 2018, of "Administration Information" for MR1 revealed no documented evidence that two RNs independently verified the new bag of medication for the patient started on September 21, 2017, at 1900 (7 PM).
Interview with EMP5 on February 2, 2018, at 11:45 AM confirmed the above findings in MR1.
2) Review on January 19, 2018, of MR5 physician's orders dated September 8, 2017, revealed, " ... fentanyl in NS (normal saline) PCA 2000 mcg/100ml premix ... ". Continued review of MR5 nursing documentation revealed "Default Flowsheet data [9/8/17 - 9/14/2017]" revealed, "Sept 9, 2017, PCA pump started at 12:02 AM." Further review revealed no documented evidence of respiratory rate and depth and level of sedation were assessed and documented every 15 minutes x 4 and every 30 minutes x 2 as required.
3) Review on January 19, 2018, of MR7 physican's orders dated November 27, 2017, revealed "hydromorphone in NS (normal saline) PCA 10mg/100 ml premix ..." Continued review of nursing documentation from November 27, 2017, thru November 28, 2017, revealed no documented evidence of respiratory rate and depth and level of sedation were assessed and documented every 15 minutes x 4 and every 30 minutes x 2 as required.
Interview on January 19, 2018, at 2:00 PM with EMP4 confirmed the above findings for MR5 and MR7.