Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 531310 (X3) Date Survey Completed 05/03/2012
Name of Provider or Supplier Powell Valley Hospital Street Address, City, State 777 Avenue H, Powell, WY
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
C0295 NURSING SERVICES
CFR(s): 485.635(d)(1)

A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient's needs and the specialized qualifications and competence of the staff available.


This STANDARD is not met as evidenced by:
Based on staff and resident interview, medical record review, and review of hospital policies and procedures, the hospital failed to ensure all necessary assessments, monitoring, and nursing measures were implemented for effective and consistent pain management for 1 of 21 sample residents (#5) who had pain. In addition, the hospital failed to thoroughly assess intermittent variances between normal and abnormal SPAO2 readings for 1 of 21 sample patients (#6). The findings were: 1. Review of the medical record for patient #5 showed s/he was admitted on 3/30/12 for rehabilitation after an open reduction and internal fixation of a fractured left femur. Review further revealed the resident had diagnoses including diabetes, chronic renal insufficiency, hypertension, and obstructive sleep apnea. Review of the physician's admission orders showed an order for Oxycodone IR 5 milligrams (mg) one to two tablets every four hours as needed for pain. Continued review of physician's orders showed the Oxycodone IR was increased to one to four tablets every four hours as needed on 4/15/12. The following concerns with pain management were identified: a. Review of the 4/4/12 nursing notes timed at 10:11 PM showed the patient had pain rated between five and six on a pain scale of 0 to 10 with 10 being the worst (5-6/10). Review of the April 2012 MAR showed the resident received Oxycodone IR 5 mg at 9:56 PM. Continued review showed the next time the patient was assessed was five hours later (3:28 AM) at which time s/he still had pain. b. Review of the 4/9/12 nursing notes timed at 11:43 AM showed the patient was tearful and in pain. The patient was administered Oxycodone IR 5 mg. Further review showed no evidence the patient's pain was re-assessed to determine the effectiveness of the medication in relieving the pain. The next notes were written at 4:55 PM (five hours later) by the PTA (physical therapy aide). Review of these PTA notes revealed the patient's ambulation was limited due to pain in the left lower extremity. c. Review of the nursing notes showed on 4/10/12 at 12:52 AM the patient complained of pain rated 8/10 and received Oxycodone IR 5 mg. Review of the nursing notes showed the resident's pain was not re-assessed until 7:36 AM (six hours later) to determine the effectiveness of the pain medication administered. In addition, there was no evidence other non-pharmacological interventions were attempted to relieve the patient's pain. d. Review of the physical therapy notes written on 4/14/12 and timed at 8:10 AM showed the patient's pain continued to limit his/her mobility and ambulation. Interview with the patient on 5/1/12 at 9 AM verfied s/he had pain, especially with any mobility or walking. e. Interview with the director of medical/surgical services on 5/3/12 at 2 PM verified the above noted incidents were accurate and that no re-assessment was performed but it should have been. Review of the second page of the hospital's policy on pain, reviewed 4/2011, showed the following instructions: "....The patient's/resident's pain will be re-assessed after every pain control mechanism employed by the patient/resident care providers as per the appropriate care setting procedure. The timing of the re-assessment (patient's/resident's response) will be dependent upon the route of administration. The re-assessment will be ....2 hours for oral and will be documented in the appropriate portion of the medical record." 2. Review of the medical record for patient #6 showed s/he was admitted after a motor vehicle accident on 5/4/11. Review of the discharge summary showed "Patient had been having some decreased pulse oximetry after administration of narcotics and while lying flat falling asleep. This was suspected due to narcotic administration, sleep apnea secondary to obesity, and atelectasis. Review of the physician progress notes written on 5/6/11 at 1:05 PM showed the patient's SPO2 (oxygen saturation level) dropped when his/her oxygen was removed and the oxygen had to be replaced. Review of the vital sign detail report showed the patient's SPO2 on 5/5/11 at 6:34 AM was 89% with 3 liters of oxygen per nasal cannula. At 6:49 AM the SPO2 was 96% with the 3 liters of oxygen and remained within normal limits (88% or above) until 12:38 PM on 5/6/11 at which point it was 85% on room air. After placing oxygen on at 2 liters the SPO2 rose to 93%. At 8 PM on that same day the SPO2 was 90% on 2 liters of oxygen. On 5/7/11 at midnight, the patient's SPO2 was 83% with oxygen at 2 liters. The nurse turned the oxygen up to 4 liters at that time which brought the SPO2 level up to 90% within 46 minutes. On 5/7/11 at 7:55 AM the SPO2 was 91% on 4 liters of oxygen. Review of the 5/7/11 nursing notes timed at 1:45 PM showed the patient was placed on room air and his/her SPO2 was maintained in the high 80's . The PA-C documented the "pt is safe for discharge." The patient was discharged on 5/7/11 at 2 PM without oxygen. The following concerns were identified: a. Review of the emergency room (ER) records showed on 5/8/11 at 2:25 PM, the patient was seen in the ER with a history of having SPO2 readings in the 40's. Further review of the ER record showed the patient was pale and short of breath upon arrival and his/her SPO2 was 88%. Further review of the ER records showed the patient required transfer via ambulance to another acute care facility with a final diagnosis of pulmonary contusion secondary to a motor vehicle accident. The patient had a history of intermittent low SPO2 throughout his/her hospital stay and required high liters of oxygen (as high as 10 liters per minutes). Upon discharge the patient had SPO2 readings in the high 80s prior to discharge but was not discharged to home with oxygen. b. Review of the ER record of 5/8/11 showed "....today, when [s/he] came back to the hospital to have her dressings changed [s/he] was found to be hypoxic and tachycardic. Patient was brought [to] the emergency room for evaluation." Review of the record showed no evidence the patient was assessed or had an SPO2 reading taken upon arrival at the hospital for the dressing change that day. Interview with the director of medical/surgical services on 5/3/12 at 2 PM revealed she was unable to find any documentation or record of the patient's admission for a dressing change on 5/8/11 but that probably due to the patient's hypoxic state upon arrival staff sent him/her to the ER for immediate evaluation. She further stated, however, there should have been documentation of the assessment of the patient's condition and disposition after arrival for his/her dressing change.