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Based on review of facility policy and medical records (MR) and staff (EMP) interviews, it was determined the facility failed to follow established policy to provide a clear distinction when therapeutic medication duplications were to be administered in five of five medical records (MR2, MR3 MR4, MR5 and MR6).

Findings include:

Review on June 8, 2020, of facility policy "Therapeutic Duplication Policy,"last revised July 31, 2019, revealed " ... Purpose: Therapeutic duplication is the practice of prescribing multiple medications for the same indication(s) or purpose without a clear distinction of when one medication should be administered over another ... Process and Guidelines: A. Medication Orders ... 3. All as needed (PRN) medication order(s) must have an indication and must contain a clear "distinction" of when the medication is to be administered if Therapeutic Duplication with another medication(s) is present ..."

Review on June 8, 2020, of MR2 revealed medications ordered for pain included "Fentanyl 25 mcg intravenous push every 5 minutes over 1-2 minutes to maximum dose of 100 mcg prn if pain scale not decreased by 2 with [blank]" and "Dilaudid 0.5mg intravenous push every 5 minutes over 1-2 minutes to maximum dose of 1 mg prn if pain scale not decreased by 2 with [blank]". There was no clear distinction of which of the therapeutic medication duplications was to be given for pain. Medications for nausea or vomiting included "Ondansetron 4 mg intravenous push over 1-2 minutes once" and "Metoclopramide 10 mg intravenous push over 1-2 minutes once". There was no clear distinction of which of the therapeutic medication duplications was to be given for nausea or vomiting.

Review on June 8, 2020, of MR3 revealed medications ordered for pain included "Fentanyl 25 mcg intravenous push every 5 minutes over 1-2 minutes to maximum dose of 100 mcg prn if pain scale not decreased by 2 with [blank]" and "Dilaudid 0.5mg intravenous push every 5 minutes over 1-2 minutes to maximum dose of 1 mg prn if pain scale not decreased by 2 with [blank]". There was no clear distinction of which of the therapeutic medication duplications was to be given for pain. Medications for nausea or vomiting included "Ondansetron 4 mg intravenous push over 1-2 minutes once" and "Metoclopramide 10 mg intravenous push over 1-2 minutes once". There was no clear distinction of which of the therapeutic medication duplications was to be given for nausea or vomiting.

Review on June 8, 2020, of MR4 revealed medications ordered for pain included "Fentanyl 10 mcg intravenous push every 5 minutes over 1-2 minutes to maximum dose of 20 mcg prn if pain scale not decreased by 2 with [blank]" and "Morphine 0.5 mg intravenous push every 5 minutes over 1-2 minutes to maximum dose of one mg prn if pain scale not decreased by 2 with [blank]". There was no clear distinction of which of the therapeutic medication duplications was to be given for pain.

Review on June 8, 2020, of MR5 revealed medications ordered for pain included "Fentanyl 25 mcg intravenous push every 5 minutes over 1-2 minutes to maximum dose of 200 mcg prn if pain scale not decreased by 2 with [blank]" and "Morphine two mg intravenous push every 5 minutes over 1-2 minutes to maximum dose of ten mg prn if pain scale not decreased by 2 with [blank]". There was no clear distinction of which of the therapeutic medication duplications was to be given for pain. Medications for nausea or vomiting included "Ondansetron 4 mg intravenous push over 1-2 minutes once" and "Promethazine 6.25 mg in 10ml 0.9% sodium chloride slow intravenous push over 3-5 minutes once". There was no clear distinction of which of the therapeutic medication duplications was to be given for nausea or vomiting.

Review on June 8, 2020, of MR6 revealed medications ordered for pain included "Fentanyl 25 mcg intravenous push every 5 minutes over 1-2 minutes to maximum dose of 200 mcg prn if pain scale not decreased by 2 with [blank]" and "Morphine two mg intravenous push every 5 minutes over 1-2 minutes to maximum dose of ten mg prn if pain scale not decreased by 2 with [blank]". There was no clear distinction of which of the therapeutic medication duplications was to be given for pain. Medications for nausea or vomiting included "Ondansetron 4 mg intravenous push over 1-2 minutes once" and "Promethazine 6.25 mg in 10ml 0.9% sodium chloride slow intravenous push over 3-5 minutes once". There was no clear distinction of which of the therapeutic medication duplications was to be given for nausea or vomiting.

Interview with EMP3 on June 8, 2020, at approximately 3:45 PM, confirmed the pain and nausea or vomiting medications ordered for MR2, MR3, MR5 and MR6 were therapeutic duplications and the instructions did not provide a clear distinction of which medication was to be administered. EMP3 further confirmed the pain medications ordered for MR4 were therapeutic duplications and the instructions did not provide a clear distinction of which medications were to be administered.