HospitalInspections.org

Based on interview, medical record and document review, the hospital failed to ensure that the nursing staff implemented its policy regarding pain management, by failing to document interventions and follow up assessments for patients with pain, for 4 of 30 patients (24, 26, 1, 2) charts reviewed. In addition, the hospital's pain scale was not clearly defined in the hospital's policy, as a result, an RN (registered nurse) administered a pain medication without clarifying the order with the physician for 1 of 30 patient (2) charts reviewed.
Findings:
1. On 2/19/13 at 1:30 P.M., a review of patient 24's medical record was conducted. Patient 24 was admitted to the hospital on 2/8/13, with diagnoses to include arthritis. Nursing documentation on 2/19/13 at 11:11 A.M., indicated that patient 24 complained of generalized aching daily pain with a pain level of 5 out of 10. The RN documented that the primary pain intervention was relaxation and stretching. Patient 24's physician's orders indicated that patient 24 could receive Tylenol extra strength 2 tablets every 6 hours as needed for pain. There was no documentation that patient 24 refused the pain medication and there was no documentation of patient 24's pain assessment following the relaxation and stretching interventions.
A review of patient 26's chart was conducted on 2/19/13 at 2 P.M. Patient 26 was admitted to the hospital on 1/27/13, with diagnoses to include depression. Nursing documentation indicated that on 2/1/13 at 10:32 A.M., Patient 26 complained of aching chronic back pain with a pain level of 5/10. The RN documented in the chart "offer PRN medication." There was no documentation that Patient 26 accepted or refused the medication, nor was there documentation of thePatient 26's follow up pain assessment.
A review of the hospital's policy and procedure titled "pain management" was reviewed on 2/19/13 at 3:30 P.M. The policy specified that "pain medication shall be administered as ordered. Effectiveness, side effects and or adverse reactions are documented and reported. Patient's response to pain alleviation interventions is evaluated and documented following the intervention. The follow up assessment includes the rating scale."
An interview with the ADON (assistant director of nurses) was conducted on 2/19/13 at 3 P.M. The ADON stated that both Patients 24 and 26 should have had documentation by the RNs regarding the pain interventions performed and the effectiveness of the interventions. She acknowledged that the nurses were not implementing the hospital's pain management policy.


21052

2. Patient 1 was admitted to the hospital on 2/15/13, per the hospital facesheet.

A review of the medication administration record (MAR) indicated that Patient 1 had an order for ibuprofen (pain medication) 600 mg (milligrams) 1 tablet every 6 hours as needed for pain. Per the same document, the patient was given 1 tablet of ibuprofen 600 mg on 2/15/13 at 6:20 A.M. A review of the patient's pain assessment record indicated that prior to the administration of the pain medication, the patient complained of pain. However, the intensity or rate of the patient's pain was not assessed. There was also no documentation related to the effectiveness of the pain medication administered.

A joint record review and interview with the Director of Nursing (DON) was conducted on 2/19/13 at 2:48 P.M. The DON acknowledged that Patient 1's pain was not thoroughly assessed prior to the administration of the pain medication. The DON also acknowledged that the effectiveness of the pain medication administered should have been assessed and documented in the patient's medical record.

A review of the hospital's policy and procedure titled Pain Management was conducted on 2/19/13 at 3:30 P.M. The policy indicated that, "Nursing staff assess all patients for pain on admission, each time vital signs are monitored, and whenever pain medication is given.....Evaluation of pain includes identifying characteristics of pain such as location, intensity, onset/duration, effects on function, current/past treatment, effects of treatment and comfort level." The policy also indicated that, "Pain medication shall be administered as ordered. Effectiveness, side effects and /or adverse reactions are documented and reported."

3. Patient 2 was admitted to the hospital on 2/17/13, per the hospital facesheet.

A review of the medication administration record (MAR) indicated that Patient 2 had an order for ibuprofen (pain medication) 600 mg (milligrams) 1 tablet every 6 hours as needed for mild and moderate pain. Per the same record, the patient was given ibuprofen 600 mg 1 tablet on 2/19/13 at 9:00 A.M. A review of the medication details record, dated 2/19/13 at 9:00, indicated that the patient was given ibuprofen 600 mg due to "mild to moderate pain." There was no clear documentation to demonstrate the patient's pain prior to the administration of the pain medication. There was no documented evidence that the patient's pain status was reassessed to monitor the pain medication's effectiveness.

A joint record review and interview with licensed vocational nurse (LVN) 1 was conducted on 2/19/13 at 2:20 P.M. LVN 1 stated that Patient 2 complained of right wrist pain at a rate of 7 out of 10 on the pain assessment scale. The interview with LVN 1 had to be stopped. LVN 1 was re-interviewed on 2/20/13 at 1:55 P.M. LVN 1 stated that Patient 2 complained of right wrist pain that was rated at "7" on 2/19/13 at 9:00 A.M. LVN 1 stated that a pain of "7" on a scale on 1 to 10 was considered severe pain. LVN 1 was asked why she gave ibuprofen 600 mg to Patient 2 when the order indicated that the medication be given to address mild and moderate pain only. LVN 1 stated that she should have called the physician to let him know that the patient complained of severe pain and that the ordered pain medication only covered mild and moderate pain. LVN 1 stated that she should have clarified the order. LVN 1 also acknowledged that the patient's pain status should have been reassessed to monitor the pain medication's effectiveness.

A review of the hospital's policy and procedure titled Pain Management was conducted on 2/19/13 at 3:30 P.M. The policy indicated that, "Nursing staff assess all patients for pain on admission, each time vital signs are monitored, and whenever pain medication is given.....Evaluation of pain includes identifying characteristics of pain such as location, intensity, onset/duration, effects on function, current/past treatment, effects of treatment and comfort level." The policy also indicated that, "Pain medication shall be administered as ordered. Effectiveness, side effects and /or adverse reactions are documented and reported." However, the policy did not define the pain scale and the different levels of pain to help guide the nursing staff when assessing pain.

Based on observation, interview, and record review, the facility failed to maintain their Emergency Power System (EPS) in accordance with NFPA 101 and NFPA 110. This was evidenced by failing to provide a functional remote alarm annunciator in a constantly attended area and by no battery-powered emergency lighting unit found by the generator. This had the potential for not being able to monitor the condition of the generator and the inability of troubleshooting a failure of the generator during the loss of power and darkness.

Findings:

During a tour of the facility with the Safety Officer and the Building Maintenance Supervisor, the generator and its components were observed.

1. On 2/19/13, at 11:28 A.M., the remote alarm annunciator for the generator was observed to be installed in the corridor of the administration building. The Building Maintenance Supervisor confirmed that the remote annunciator was not functioning and the maintenance records did not show that it had been tested. The one line diagram showed that the generator may be used as a secondary power source during a power outage, including but not limited to the following electrical equipment: emergency lights, exits signs, emergency receptacle wall outlets, and the fire alarm system.

2. On 2/19/13, at 11:42 A.M., the area where the generator was located did not have a battery-powered emergency lighting unit. The Building Maintenance Supervisor confirmed that there was no battery-powered lighting unit.

Based on observation and record review, the facility failed to maintain self-closing devices on fire doors. This was evidenced by rolling fire doors that were not kept in proper working condition, and affected 3 of 4 hospital units. This could result in smoke and fire to travel throughout the facility in the event of a fire in the rooms. The facility also failed to ensure that their fire alarm system was installed appropriately. This was evidenced by access controlled egress doors that failed to unlock automatically upon activating the fire alarm system. This affected 2 of 4 units. This could result in delays during a fire evacuation, resulting in injury to patients, staff, and visitors. In addition, the facility failed to maintain the operational integrity of the fire alarm system. This was evidenced by 40 of 370 fire alarm smoke detectors that failed sensitivity testing, and duct detectors that failed to shutdown equipment in 2 of 4 units. This had the potential to have a fire alarm system not function which could result in a delayed response to a fire, increasing the risk of injury to patients, visitors, and staff.

Findings:

1. During a tour of the facility with the Safety Officer and the Building Maintenance Supervisor, the rolling fire doors were observed and annual inspection records were reviewed.

On 2/19/2013, at 12:07 P.M., the vendor's inspection records identified 3 of 11 rolling fire doors were not checked for proper operation during an inspection. The doors included C32 in Unit C (Serial #430021), B42 in Unit B, and D40 in Unit D (Serial #430017). The fire alarm technician stated that the rolling fire doors had not been inspected because the doors required repairs.


2. During a tour of the facility with the Safety Officer and the fire alarm technician, the fire alarm system and the sprinkler system were observed and records were reviewed.

a. On 2/20/2013 at 8:45 a.m., the cross corridor Access-Controlled Egress Doors by Room B51 failed to unlock upon activating a smoke detector in the area. An exit sign was displayed by the door.

b. On 2/20/2013, at 8:46 a.m., the cross corridor Access-Controlled Egress Doors by Room B47 failed to unlock upon activating a smoke detector in the area. An exit sign was displayed by the door.

c. On 2/20/2013, at 8:50 a.m., the cross corridor Access-Controlled Egress Doors by Room B65 failed to unlock upon activating a smoke detector in the area. An exit sign was displayed by the door.

d. On 2/20/2013, at 9:02 a.m., the cross corridor Access-Controlled Egress Doors by Room C73 failed to unlock upon activating a smoke detector in the area. An exit sign was displayed by the door.

The Safety Officer stated that the Access-Controlled Egress Doors is an ongoing project through the Office of Statewide Health Planning & Development (OSHPD). The fire alarm technician stated that change orders had been submitted and that OSHPD is planning on doing a field visit. OSHPD's citizen access website had indicated that a building permit had been issued on 1/31/2012.


3. During a tour of the facility with the Safety Officer and the fire alarm technician, the fire alarm systems were tested, observed, and documents were reviewed.

a. On 2/19/2013, at 12:20 p.m., the fire alarm annual report, dated 1/11/2013 and 1/10/2012, showed that the duct detectors failed to shut down air flow equipment in air ducts located in Unit B and Unit C. There was no record that showed the replacement or repair of the equipment. The fire alarm technician stated that the repairs had not been completed. The Assistant Administrator stated that Unit B is currently inactive and Unit C is active with the potential of serving up to 34 patients.

b. On 2/19/2013, at 12:40 p.m., the log showing the smoke detector sensitivity test identified 40 of 370 smoke detectors out of range. There was no documentation for repair or replacement of the smoke detector. The fire alarm technician stated that he had compiled the list through quarterly inspections he had conducted in the past year, beginning on 3/14/2012.

c. On 2/19/2013, the fire alarm system inspection and testing records did not include testing all the items listed in section 7-5.2.2 of NFPA 72.

Based on staff interviews and record review, the facility failed to ensure that staff members were aware of their duties to protect patients in the event of a fire. This was evidenced by a staff who did not know the difference between two types of fire extinguishers, a staff who did not know the difference between the building's fire alarm system and the kitchen's fire suppression system, failing to conduct fire drills under varying conditions, and incomplete fire drill records. This had the potential for staff members to not properly respond to a fire that could result in harm to patients, staff, and visitors.

Findings:

During a tour of the facility with the Safety Officer, facility staffs were interviewed to determine their knowledge of their fire emergency procedures and usage of life safety equipments, and fire drill records were reviewed.

1. On 2/19/2013, at 4:03 P.M., kitchen staff 1 was asked how he would respond to a fire in his working area and to explain the difference between the two types of fire extinguishers located in the kitchen. Kitchen staff 1 was unable to identify what type of fire extinguisher to use during an oil or grease fire and he could not explain the difference between the K-type and the ABC-type fire extinguishers.

2. On 2/20/2013, at 8:20 A.M., kitchen staff 2 was asked how she would respond to a fire and where she would activate the fire alarm system. She pointed at the handle used to manually activate the kitchen's hood fire suppression system. Kitchen staff 2 was then asked to explain the difference between the manual fire alarm box and the hood's fire suppression system. She was unable to explain the difference between the two systems.

3. On 2/20/2013, at 3:45 P.M., the fire drill records were reviewed for the past 12 months, and did not show that a fire alarm signal was transmitted for drills conducted during 7 a.m. to 9 p.m. time frames.

4. On 2/20/2013, at 3:50 P.M., the fire drill records were reviewed for the past 12 months and did not show that fire drills were done in varying times. Drills were recorded to be done in the morning at 7 A.M. for the first, second, third, and fourth quarters, and at 4 P.M. for the first, third, and fourth quarters.

A review of kitchen staff 1 and 2's employee files was conducted on 2/21/13 at 8:45 A.M. There was no documented evidence that both kitchen staff received education regarding fire safety.

An interview with the hospital's Safety Officer (SO) was conducted on 2/21/13 at 10:15 A.M. The SO stated that both kitchen staff 1 and 2 received education regarding fire safety. However, the SO acknowledged that there was no documentation to prove that the education occurred.

Based on observation, the facility failed to maintain corridor doors. This was evidenced by doors opening into the corridor with impediments that kept them from closing and latching. This affected 2 of 4 units. This could delay the containment of smoke and fire, resulting in injury to residents, staff, and visitors.

Findings:

During a tour of the facility with the Safety Officer, the corridor doors were observed.

1. On 2/20/2013, at 1:29 P.M., the corridor door to Conference Room D27 had its latching mechanism taped, which prevented the door from positive latching.

2. On 2/20/2013, at 2:11 P.M, the corridor door to Room A49 had a door wedge that prevented the door from closing. No one was in the room during this observation.

3. On 2/20/2013, at 2:12 P.M., the corridor door to Room A50 had a door wedge that prevented the door from closing. No one was in the room during this observation.