HospitalInspections.org

Based on observation record review and interview the facility failed to assure drugs and biologicals were prepared and administered in accordance with the orders of the practitioner or practitioners responsible for the patient's care and accepted standards of practice for one (1) of thirteen (13) sampled patient records. (#2)

Findings:

Review of record # 2 reflected on the physician orders an order for Albumin 25 grams (GM) intravenous (IV) every eight hours times six doses on 04/13/2011. The Medication Administration Record (MAR) reflected that the six doses of Albumin were given. The intake and output (I&O) documentation reflected 50 cc given at 6:00 a.m. on 03/14/2011 for the dose of Albumin given on 03/14/2011. The I&O documentation for the other five doses reflected 100 cc administered.
Interview with staff nurse from progressive care unit (PCU) on 06/15/2011 at 3:00 p.m. confirmed that the nursing staff would document both on the MAR that the dose was given and on the I&O the amount of fluid. Interview of the Director of Pharmacy on 06/15/2011 at 4:00 p.m. confirmed that Albumin comes in both 50 cc with 12.5 GM of Albumin and 100 cc with 25 GM of Albumin. He also confirmed that the pharmacy often sends two (2) 50 cc bags of Albumin for an order of 25 GM. Review of the pharmacy reconciliation for patient #2 reflected that the pharmacy sent two 50 cc bags.
Interview of the Nurse Manager of PCU, the Patient Care Administrator, and the Director of Pharmacy on 06/15/2011 at 4:00 p.m. confirmed the record review was complete as reviewed.