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Based on interview, clinical record review and document review the facility failed to ensure pain assessments had been completed for 1 of 27 sampled patients (Patient # 25).

Findings include:

Patient #25 was admitted to the facility on 4/27/19 with diagnosis including right knee infection status post explant of right total knee arthroplasty, diabetic neuropathy and gout. The patient was discharged on 5/21/19.

The clinical record documented the patient was alert and orientated times four.

The Discharge Summary dated 5/20/19, documented the patient was at an acute care hospital for a right knee infection. The patient underwent explant and an antibiotic spacer. The patient was transferred to the facility for continued antibiotic treatment.

The Initial Nursing Assessment dated 04/27/19 at 9:00 PM, documented the patient had chronic pain. The patient was currently enrolled with an external pain management clinic. The current pain status documented the patient had right knee pain with a rating of 9, which indicated severe/worst. The pain had been described as sharp and medication was used as a relief measure.

A Physician's Order dated 04/27/19, documented Percocet 10/325 milligrams (mg) one tablet orally every 4 hours as needed for severe pain of 7-10 out of 10 on the pain scale.

The Medication Administration Record for 04/27/19 at 6:00 AM, to 04/28/19 at 5:59 AM, documented the patient had received Percocet 10/325 mg one tablet orally at 2:05 AM.

A Nurses Note dated 4/28/19, lacked documented evidence the patient's pain level had been assessed.

On 06/06/19 at 9:35 AM, a Nurse Manager verbalized on the medical/surgical unit which this patient had been admitted, the standard was to assess the patients pain every shift. The Nurse Manager explained staff should have been assessing the patient every time they entered the room to see the patient. The Nurse Manager confirmed there was no documented evidence a pain assessment had been completed on 4/28/19 for the 24 hour period.

A Facility document titled Pain Management Plan (undated) documented the assessment of pain and adequacy of treatment were re-assessed at regular intervals, appropriate to the patient's condition but not less that once every shift.

Based on interview, document review and policy review the facility failed to ensure a care plan for pain had been completed for 4 of 27 sampled patients (Patient # 25, #3, #7 and #20) and failed to ensure a care plan for restraints had been completed for 1 of 27 sampled patients (Patient #7) .

Findings include:

Patient #25 was admitted to the facility on 4/27/19 with diagnosis including right knee infection status post explant of right total knee arthroplasty, diabetic neuropathy and gout. The patient was discharged on 5/21/19.

The Initial Nursing Assessment dated 04/27/19 at 9:00 PM, documented the patient had chronic pain. The patient was currently enrolled with an external pain management clinic. The current pain status documented the patient had right knee pain with a pain scale rating of 9, which indicated severe/worst. The pain had been described as sharp and medication had been used as a relief measure.

A Physician's Order dated 04/27/19 documented Percocet 10/325 milligrams (mg) one tablet orally every 4 hours as needed for severe pain of 7-10 out of 10 on the pain scale.

A Transdisciplinary Plan of Care for Pain dated 05/05/19, documented the basic care included a pain assessment every shift using the pain scale.

On 06/06/19 at 9:35 AM, a Nurse Manager indicated the care plan for pain should have been initiated based upon the patient's diagnosis. The care plan for pain should have been initiated earlier due to the patient's pain. The Nurse Manager verbalized the pain care plan had not been completed. The outcomes and as evidenced by sections on the care plan had not been completed and should have been completed.




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Patient #3

Patient # 3 was admitted to the facility on 5/28/19 with diagnoses to include left cerebellar brain tumor, status post suboccipital craniotomy, placement of ventriculoperitoneal shunt and bihemispheric strokes. The patient was admitted from an acute care hospital for continuation of medical management and rehabilitation. Patient had a tracheostomy requiring ventilator management and a PEG (Percutaneous Endoscopic Gastrostomy) tube receiving parenteral feeding.

The Transdisciplinary Plan of Care was initiated on 5/28/19, and the initial team conference was held on 5/29/19. The plan of care lacked documentation for pain management.

A consultation note of evaluation for rehabilitation and pain management dated 5/30/19, documented the patient was currently on Tylenol as needed for breakthrough pain; however due to elevated laboratory levels, the Tylenol was discontinued.

On 6/4/19 at 1:15 PM, a Registered Nurse (RN) and a Nurse Manager reviewed the care plan and indicated the plan of care for pain should have been initiated upon admission based upon the patient's diagnosis. The Nurse manager verbalized the pain care plan had not been completed and should have been.

Patient #7

Patient #7 was admitted to the facility on 5/29/19 with diagnoses to include acute respiratory failure, cerebral vascular accident, seizures and intraparenchymal hemorrhage of brain. The patient was admitted from an acute care hospital for continuation of medical management and rehabilitation. The patient had a tracheostomy requiring ventilator management and a PEG (Percutaneous Endoscopic Gastrostomy) tube receiving parenteral feeding. The patient had contracture of right arm and a mitt restraint was intact on left hand.

The Transdisciplinary Plan of Care was initiated on 5/29/19 and the initial team conference was held on 5/30/19. The plan of care lacked documentation for pain management.

A consultation note of evaluation for rehabilitation and pain management dated 5/30/19, documented the patient was currently on Norco as needed for breakthrough pain; however due to elevated laboratory levels, recommended judicious use of Tylenol and would adjust pain medications accordingly. The plan of care lacked documentation for pain management.

The Transdisciplinary Plan of Care initiated on 5/29/19 at 8:00 PM, documented Restraints as a Significant Problem/Barrier to Discharge. An entry at 1834 (6:34 PM) for evaluation notes documented Pt (patient) came with left mitten. Patient had AMS (altered mental status) due to CVA, attempted to pull at lines. Left mitten restrained- Pt's husband aware and verbalized understanding. No further entries were documented on the care plan.

On 6/4/19 at 2:00 PM, a Nurse Manager reviewed the plan of care and indicated the plan of care for pain should had been initiated upon admission based upon the patient's diagnosis. The Nurse manager verbalized the pain plan of care had not been completed and should had been. The Nurse Manager indicated the restraint plan of care should had been updated at the Transdisciplinary Care meeting.

Patient #20

Patient #20 was admitted to the facility on 5/13/19 with diagnoses to include acute respiratory failure, crushing tracheal injury and acute blood loss. The patient was admitted from an acute care hospital for continuation of medical and ventilatory management. Patient had a tracheostomy requiring ventilator management and a PEG (Percutaneous Endoscopic Gastrostomy) tube receiving parenteral feeding.

The Nurses notes dated 5/25, 5/27, 5/29, 5/31, 6/2, 6/4 and 6/5/19 documented pain levels of 0 - 1 and lack of documentation of pain levels. Pain levels were assessed inconsistently utilizing either the Wong-Baker Faces Scale or the FLACC Scale (The Face, Legs, Activity, Cry, Consolability scale is a measurement used to assess pain for children between the ages of 2 months and 7 years or individuals that are unable to communicate their pain).

Review of MARs (Medication Administration Records) documented an order dated 6/4/19 for Tylenol 650 mg every 6 hours prn (as needed) for pain per PEG.

The Nurses Note dated 6/4/19 at 8:12 PM, documented a pain level of 1 using the FLACC scale, described as grimace. MAR lacks documentation of pain medication given at this time.

The Transdisciplinary Plan of Care was initiated on 5/13/19 and the initial team conference was held on 5/15/19. The plan of care documented pain management as a significant problem/barrier to discharge. The plan of care documentation for pain managed lacked documentation of outcomes, as evidenced by statements and basic care to include. Other interventions documented an entry on 5/13 which notated two medications (Tylenol and Oxycodone) ordered for pain management.

On 6/5/19 at 10:00 AM, a Nurse Manager reviewed the plan of care and indicated the plan of care for pain should had been completed to include outcomes, evidenced by statements and the basic care to provide upon admission. The Nurse manager verbalized the pain plan of care had not been completed in it's entirety and should had been. The Nurse Manager indicated the pain management plan should had been updated at the Transdisciplinary Care meeting.

A Facility document titled Pain Management Plan (undated) documented a pain treatment plan was developed for each patient based on evidence-based practices and the patient's clinical condition, past medical history and pain management goals.

The facility's policy titled Transdisciplinary Care Planning, approved on 6/1/18, documented patient care needs were identified and prioritized and a plan of care which appropriately address priority needs, was initiated within approximately 24 hours of admission. Following the evaluations of other disciplines, the Transdisciplinary Care team would meet formally (within approximately 24 hours after admission) to further develop the plan.

Based on observation, interview and document review the facility failed to ensure 1.) intravenous (IV) tubing was labeled and dated for 4 of 27 sampled patients (Patient #11, #13, #7 and #6); 2.) ensure an IV site dressing was labeled and dated for 1 of 27 sampled patients (Patient #4); 3.) ensure oxygen tubing and humidifier bottles were labeled and dated for 3 of 27 sampled patients (Patient #6, #13 and #11 ); 4.) ensure tube feeding solutions and the tubings were labeled and dated for 3 of 27 sampled patients (Patient #6, #7 and #11 ).

Findings include:

On 06/04/19 between 10:40 AM, and 11:30 AM, during a tour of the 300 hallway the following was observed and confirmed with the Director of Quality:

Patient #4 was up in a chair in the room. The patient had IV access in the right forearm. The IV dressing was not dated.

On 06/04/19 at 11:07 AM, a Registered Nurse (RN) verbalized dressing changes on IV sites was done every Sunday. The RN explained the policy at the facility was to date IV tubing and IV bags with a sticker. The RN indicated the sticker on the Normal Saline and the IV piggy back should be dated.

Patient #6 was in bed with eyes closed. A tube feeding solution of Vital 1.5 was running at 40 milliliters (ml) per hour. The Vital solution container lacked documentation of the time and date the solution had been hung. On the IV pole in the room was an IV piggy back bag which contained Cipro. The IV tubing on the Cipro piggy back had not been labeled or dated. A Kangaroo bag with a clear liquid was hung without a label or date to determine when the clear liquid had been hung. An oxygen humidifier bottle and oxygen tubing were connected to the wall oxygen. The humidifier bottle and oxygen tubing were not labeled or dated.

On 06/04/19 at 11:10 AM, the Director of Quality explained the following should be labeled and dated:
IV tubing,
Tube feeding containers as well as the
The tubing for the tube feeding
The oxygen humidifier and oxygen tubing

On 06/04/19 at 11:20 AM, Patient #11 was in bed with eyes closed. A 500 ml bag of Normal Saline with tubing was hanging on an IV pole in the room. The IV tubing for the Normal Saline had not been labeled or dated. An IV tubing and a piggy back of Meropenem were on the IV pole. The IV tubing had not been labeled or dated. Osmolite 1.5 calorie tube feeding solution was at 45 ml per hour . The Osmolite solution and the tubing had not been labeled or dated. A Kangaroo bag which contained clear liquid and the tubing for the kangaroo bag had not been labeled or dated. An oxygen humidifier bottle and oxygen tubing were connected to the wall oxygen. The humidifier bottle and oxygen tubing were not labeled or dated.

On 06/05/19 at 11:35 AM, the Chief Nursing Officer (CNO) verbalized the labeling and dating of IV tubing and tube feeding should be completed on daily surveillance.




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Patient #13

Patient #13 was admitted on 6/3/19 with diagnoses including acute hypoxic respiratory failure, obstructive lung disease. On 6/4/19 at 1:40 PM, Patient #13 was upright in bed with oxygen on by nasal cannula. The patient had IV (intravenous) access in the left forearm.

A 1 Liter bag of normal saline 0.9% and a 50 milliliter bag of Piperacillin were not labeled or dated. A Nurse Manager was present and confirmed neither were labeled or dated and should had been.

A high flow nasal cannula was connected to a bag of Inhalation solution. The inhalation solution and oxygen tubing were not labeled or dated. On 6/3/19 at 1:50 PM, a Respiratory Therapist (RT) verbalized both should had been labeled and dated.

Patient #7

Patient #7 was admitted to the facility on 5/29/19 with diagnoses to include acute respiratory failure, cerebral vascular accident, seizures and intraparenchymal hemorrhage of brain. On 6/4/19 at 2:00 PM, Patient #7 was lying in the bed with eyes closed. The patient had IV access in the right hand.

A 500 ml bag of Normal Saline with tubing was hanging on an IV pole in the room. The IV tubing for the Normal Saline had not been labeled or dated. An IV tubing and a piggy back of Keppra were on the IV pole. The IV tubing had not been labeled or dated.

Glucerna 1.5 calorie tube feeding solution was at 45 ml per hour . The Osmolite solution and the tubing had not been labeled or dated. A Kangaroo bag which contained clear liquid and the tubing for the kangaroo bag had not been labeled or dated.

On 06/04/19 at 2:00 PM, an RN verbalized the labeling and dating of IV tubing and tube feeding should had been on the bags. A Nurse Manager was present and confirmed neither were labeled or dated and should had been.

Facility documentation on IV administration set (tubing) changes from Lippincott Procedures revised 05/18/19, indicated label the administration set and solution container with the date of initiation or the date when change was necessary as directed by your facility.

Facility documentation on IV dressing changes from Lippincott Procedures (undated) documented label the dressing with the date you changed the dressing or the next date the dressing change would be do to be changed as directed by your facility.