QA Investigation Results

Pennsylvania Department of Health
MILTON S HERSHEY MEDICAL CENTER
Health Inspection Results
MILTON S HERSHEY MEDICAL CENTER
Health Inspection Results For:


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Initial Comments:

This report is the result of an unannounced onsite Federal complaint investigation (CHL14CVOFH) completed on September 18, 2014, at Milton S. Hershey Medical Center. It was determined the facility was not in compliance with the requirements of 42 CFR, Title 42, Part 482-Conditions of Participation for Hospitals.













Plan of Correction:




482.23(b)(3) STANDARD
RN SUPERVISION OF NURSING CARE

Name - Component - 00
A registered nurse must supervise and evaluate the nursing care for each patient.


Observations:


Based on review of facility policy, medical record (MR), and interview with staff (EMP), it was determined the facility failed to evaluate the nursing care, in accordance with their pain assessment policy, for three of four medical records reviewed (MR6, MR7 and MR9).

Findings include:

A review on September 16, 2014, of "facility policy "Pain Management Inpatient/Ambulatory Care" effective July 2014 revealed, "...Pain interventions will be instituted when a patient reports an unacceptable level of pain, as perceived by the patient. ... Pain is assessed as follows: a. Mild (total score of 1-3) b. Moderate (total score 4-6) c. Severe (total score 7-10) a. The effectiveness of the intervention will be evaluated at 30 minutes for IV administration b. The effectiveness of the intervention will be evaluated at 60 minutes for PO medication and non-pharmacologic interventions. ..."

A review on September 16, 2014, of MR6 revealed the patient was administered Oxycodone 10 milligrams (mg) po (by mouth) on September 15, 2014, at 5:16 PM and 11:19 PM. The MR6 failed to contain evidence of an assessment of the pain level and the effectiveness of the intervention.

A review on September 16, 2014, of MR8 revealed the patient received Morphine 2 mg IV (intravenous) on September 15, 2014, at 8:19 PM. MR8 failed to contain evidence that the patient was reassessed in 30 minutes.

A review on September 16, 2014, of MR9 revealed the patient received Dilaudid 0.4 mg IV on September 15, 2014, at 12 midnight. MR9 failed to contain evidence that the patient was reassessed in 30 minutes.

An interview conducted on September 16, 2014, between 11:15 AM through 1:00 PM with EMP2, confirmed the facility did not follow their policy for the assessment of pain level and/or the effectiveness of intervention for MR6, MR8 and MR9.






Plan of Correction:

On 9/26/14, the Penn State Hershey Medical Center (PSHMC) Neuro Critical Care Unit (NCCU) Manager/designee will send the “Pain Management Inpatient/Ambulatory Care” policy to all NCCU RN staff with instructions that they are to review the policy. The email will remind staff that per policy the pain level is to be documented prior to administration of pain medication. The effectiveness of the pain medication intervention is to be documented 30 min post IV pain medication administration or 60 min post po pain medication administration.

On a weekly basis, starting 10/6/14, the NCCU nursing Manager/designee will select 20 patient records at random from patients currently in the unit, and will evaluate the most recent pain administration documentation for the following criteria: (1) Was the pain level assessed, per policy, prior to administration of pain medication (2) Was the pain level assessed, per policy, post medication administration.


The NCCU Manager/designee will take corrective action as needed for any noncompliance with the pain management policy to ensure compliance is achieved and maintained. Audits will occur for a minimum of 2 months and continue until compliance is achieved.



Initial Comments:


This report is the result of an unannounced onsite complaint investigation (CHL14CV0FH) completed on September 18, 2014, at Milton S Hershey Medical Center. It was determined the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 PA Code, Part IV, Subparts A and B, November 1987, as amended June 1998.










Plan of Correction:




109.21 LICENSURE
POLICIES - PRINCIPLE

Name - Component - 00
109.21 Principle

Written nursing care and administrative policies and procedures shall be developed to provide the nursing staff with methods of meeting its responsibilities and achieving goals.

Observations:

Based on review of facility policy, medical record (MR), and interview with staff (EMP), it was determined the facility failed to follow their policy for the assessment of pain for three of four medical records reviewed (MR6, MR7 and MR9).

Findings include:

A review on September 16, 2014, of "facility policy "Pain Management Inpatient/Ambulatory Care" effective July 2014 revealed, "...Pain interventions will be instituted when a patient reports an unacceptable level of pain, as perceived by the patient. ... Pain is assessed as follows: a. Mild (total score of 1-3) b. Moderate (total score 4-6) c. Severe (total score 7-10) a. The effectiveness of the intervention will be evaluated at 30 minutes for IV administration b. The effectiveness of the intervention will be evaluated at 60 minutes for PO medication and non-pharmacologic interventions. ..."

A review on September 16, 2014, of MR6 revealed the patient was administered Oxycodone 10 milligrams (mg) po (by mouth) on September 15, 2014, at 5:16PM and 11:19 PM. The MR6 failed to contain evidence of an assessment of the pain level and the effectiveness of the intervention.

A review on September 16, 2014, of MR8 revealed the patient received Morphine 2 mg IV (intravenous) on September 15, 2014, at 8:19 PM. MR8 failed to contain evidence that the patient was reassessed in 30 minutes.

A review on September 16, 2014, of MR9 revealed the patient received Dilaudid 0.4 mg IV on September 15, 2014, at 12 midnight. MR9 failed to contain evidence that the patient was reassessed in 30 minutes.

An interview conducted on September 16, 2014, between 11:15 AM through 1:00 PM with EMP2, confirmed the facility did not follow their policy for the assessment of pain levels and/or the effectiveness of intervention for MR6, MR8 and MR9.



















Plan of Correction:

On 9/26/14, the Penn State Hershey Medical Center (PSHMC) Neuro Critical Care Unit (NCCU) Manager/designee will send the “Pain Management Inpatient/Ambulatory Care” policy to all NCCU RN staff with instructions that they are to review the policy. The email will remind staff that per policy the pain level is to be documented prior to administration of pain medication. The effectiveness of the pain medication intervention is to be documented 30 min post IV pain medication administration or 60 min post po pain medication administration.

On a weekly basis, starting 10/6/14, the NCCU nursing Manager/designee will select 20 patient records at random from patients currently in the unit, and will evaluate the most recent pain administration documentation for the following criteria: (1) Was the pain level assessed, per policy, prior to administration of pain medication (2) Was the pain level assessed, per policy, post medication administration.

The NCCU Manager/designee will take corrective action as needed for any noncompliance with the pain management policy to ensure compliance is achieved and maintained. Audits will occur for a minimum of 2 months and continue until compliance is achieved.