Based on record review and interview, the facility failed to ensure that medications for the treatment of pain were reassessed in accordance with hospital policies and accepted standards of practice. This failure resulted in 3 of 4 patients (Patient #2, #4, and Patient #6) being administered a pain medication and not having a reassessment of the effectiveness of the medication. Record review of the medication administration record of Patient #2 showed morphine 2mg was given on 3/6/17 at 2:25 AM for leg pain. There was not reassessment of the pain to determine the effectiveness of the morphine. Record review of the medication administration record of Patient #4 showed morphine 2mg was given on 5/14/19 at 5:45 AM for abdominal pain. There was no reassessment of the pain to determine the effectiveness of the morphine. Record review of the medication administration record of Patient #6 showed Norco 5/325mg was given on 5/13/19 at 7:57 AM. There was no reassessment of the pain to determine the effectiveness of the Norco. In an interview with Staff #55 on 5/14/19 at 10:00 AM, Staff #55 stated that pain is to be reassessed to determine the effectiveness of a pain medication. Record review of the policy, Pain Assessment and Reassessment, Management, and Documentation, last reviewed 7/2017, showed: Patients have the right to appropriate assessment and management of pain ... Pain will be reassessed after a pain intervention is performed. When administering non-PCA pain medications. Pain reassessment will be done within an hour of administering pain medications ... RN.LVN responsible for ... reviewing and documenting effectiveness of pain medication ... Record review of recommendations for improving the quality of acute and cancer pain management by D. Gordon and C. Miaskowski of the American Pain Society Quality of Care Task Force [2005; 165(14):1574-1580] showed: The American Pain Society published the most current guidelines in 2005 for improving the management of acute pain ... The 5 most current guidelines include prompt recognition and treatment of pain, involvement of patients in the pain management plan, improvement of treatment patterns, reassessment and adjustment of the pain management plan as needed, and monitoring processes and outcomes of pain management.
Based on interview and record review, in 1 of 1 credentialing file reviewed, the facility failed to follow Medical Staff Services policy titled: Practitioner Health and Wellness. Once receiving notification of physician condition, there was no written request to investigate submitted to Peer Review Committee. Findings include: Chief nursing officer (ID# 51) and Director of Medical Staff Services (ID# 83) on 1/2/2016 at 12:41 stated that there is no documentation in February or March meeting minutes for peer review, medical executive committee, or Board of Trustee meeting regarding reported condition physician (ID# 54), nor is there a written request to investigate. Record review of credentialing file for physician (ID# 54) revealed a letter dated 2/20/2015 from health care provider (ID# 84) regarding the medical condition of physician (ID#54). This letter expressed presenting symptoms, treatment and medical studies conducted. In the conclusion of this letter, it is stated that physician (ID#54) does not currently demonstrate disabling symptoms of Parkinson's disease and should be able to continue functioning in his practice. Record review of facility policy for the department of medical staff services titled: Practitioner Health and Wellness (no date on policy) revealed the following information: Policy: 1. Any individual who has clinical privileges must maintain physical and mental health status sufficient to carry out those privileges in a safe manner. 2. Reports or concerns about impairment must be investigated and acted upon in a timely manner and in accordance with state and federal law, including, but not limited to, the Americans with Disabilities Act (ADA). Definition: b. Physical illness or condition, including but limited to those illnesses or conditions that would adversely affect cognitive, motor, or perceptive skills, including deterioration through the aging process. Procedure: Self reporting-Application process 1. During the application process, all applicants must report information about their ability to perform the clinical privileges they are requesting. Each medical staff member or other individual with clinical privileges is responsible for reporting any change in his/her abilities that might possibly affect the quality of patient care rendered by him/her as related to the performance of his/her clinical privileges and/or medical staff duties. Such reports should be made immediately upon the individual becoming aware of the change. 2. A written report must be given to the Chief Executive officer, the Chief of Staff, the Chairperson of the individual's medical staff department, and/or the chairperson of the credentials committee. The recipient of this letter shall submit it, along with a written request to investigate, to the Peer Review Committee.
Based on interview and record review, the facility failed to report 1 of 2 preventable adverse events (PAE) to the Texas Health Care Safety Network (TxHSN) and to complete a root cause analysis (RCA) for 1 of 3 adverse events reviewed. Findings include: Interview with Chief Nursing Officer ( ID# 51) on 11/1/2016 at 2:20 PM revealed that adverse event (wrong surgical procedure) performed 3/11/15, involving patient (ID# 3) was not reported to the state as required and that it should have been. Interview with Chief Nursing Officer (ID# 51) on 11/2/2016 at 9:35 AM revealed that in regard to adverse advent (wrong surgical procedure) that occurred with patient (ID# 3) on 3/11/2015, there was no incident report generated when the facility was notified. There was no documentation of a root cause analysis (RCA) performed regarding the event. There was an investigation performed, but no documentation to review that shows the investigation process. Record review of Texas Department of State Health Services Facility-Specific Healthcare Safety Report of preventable adverse events reported from January 2015-July 2015 for Conroe Regional Medical Center reveled the following information. Preventable Adverse Events (PAEs) Events related to patient care: Total Number of 1 Patient death or severe harm associated with a fall in the healthcare facility that caused a broken bone. Record review of the Texas Department of State Health Services 3 Tier Phase -In Implementation for Preventable Adverse Events (PAE) revealed the following information: First Tier PAE Reporting Beginning January 1, 2015 1. Surgeries or invasive procedures involving a surgery on the wrong patient, wrong procedure. 10. Patient death or severe harm associated with a fall in a healthcare facility resulting in fracture, dislocation, intracranial injury, crushing injury, burn or other injury. Record review of facility policy titled Event Reporting: Patient and Non-Patient dated 01/2012 revealed the following information: Purpose: -To provide a record of events and documentation of the facts -To provide a base for further investigation with a focus on a patient safety and environmental safety processes and systems, and the corrective measures needed to prevent recurrence and sustain improvement -To collect data for statistical analysis -To fulfill regulatory requirements for reporting events -to alert Risk Management to potential claim situations Policy: -Adverse events, errors, unexpected events, variances, incidents, and near misses involving patients will promptly reported online in the Meditech Risk Management Patient Notification System even if the event seems insignificant at the time. -Event reports are intended to provide a record of the event and document the facts - Event reporting is an important part of the Hospital-wide focus on safety and performance improvement. - Event reporting is a system of notification to Hospital leadership of actual or potential risks and patient safety issues/concerns. -Events reports should be completed during the shift the event occurs or is discovered to have occurred. Supervisor, Manager and Director Review responsibilities: 2. Service leaders are responsible for prompt (within 72 hours) initial review of all information entered by the employee and for conducting an investigation to determine root cause and follow-up to ensure resolution of identified issues/concerns. 4. Results of investigations should be shared with the staff with a focus on process and systems design and redesign and outcome, and the corrective measures needed to prevent recurrence and sustain improvement.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure that one of six sampled patients (Patient #1) fully participated in her discharge plan of care. The facility failed to: ? Verify and discuss family contact information, ? Assess and evaluate family support options, and ? Provide safe travel arrangements to return home. Findings include: TX 790 Record review of intake # 790 revealed statements by Patient #1 in which she described a fall at home on 05/13/14, followed by a call to 911 and transportation to the hospital. After tests were run, she was returned home in a cab despite her protest of the discharge and request for further treatment. Record review of Patient #1's Emergency Department (ED) record dated 05/15/14 revealed an [AGE] year old who arrived by ambulance at 4:15 PM with complaints of back pain and generalized weakness following a fall at home. Record review of Patient #1's x-ray of pelvis and bilateral hips and computed tomography of the left hip dated 05/15/14 showed degenerative changes with no fracture. Record review of the Nursing Notes dated 05/15/14 at 7:30 PM revealed that Patient #1 was discharged home in a cab. Further review of the Nursing Notes failed to reveal documentation that staff attempted to contact her family at any time during this ED visit. Interview on 02/11/15 at 03:00 PM with the Chief Nursing Officer (#52) revealed acknowledgements that Patient #1's disposition home should have been handled differently. There should have been family involvement in the discharge plan and a different mode of transportation should have been provided for her. Interviews on 02/11/15 at 10:55 AM with ED Registered Nurses (#53, #54 and #61): all three stated that in this situation, Patient #1's family should have been contacted and the patient should not have been sent home alone in a cab. Review of the facility policy titled Patient Rights and Responsibilities/Provisions for the Disabled dated 08/2012 reads, 1. The Patient has the right to: ... (b) Reasonable safety insofar as the hospital practices ... are concerned ... (f) Be involved in care planning and treatment ... (j) Have a family member or representative of his choice ... notified promptly of his admission to the hospital.
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