HospitalInspections.org

Based on administrative and clinical record review and staff interview the facility failed to administer medications in accordance to the practitioner's prescription, for 2 of 4 sampled patients (Patient # 8 and # 9 ). The facility's policy for medication Administration was not followed.

The findings include:

1) Review of the clinical record for Patient # 9, revealed physician orders for Valproic Acid 1000 mg every 6 hours. Review of the Medication Administration record (MAR) disclosed the nursing staff failed to correctly administer 10 doses of the prescribed medication. These 10 doses were not administered as prescribed or were not administered within appropriate time per the facility's policy. The medication are scheduled for 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM. According to the facility ' s policy and procedure for medication administration, medication is to be administered at the right time. The right time is identified as 30 minutes before and/or after the scheduled time.

The following doses were not administered as prescribed:
l. 8/23/2012 1:51 PM (1 hour and 51 minutes past the 12:00 PM dose)
2. 8/24/2012 - no 6:00 PM dose administered
3. 8/26/2012 - 2:53 PM (almost 3 hours after the 12:00 PM dose was due.)
4. 8/28/2012 - 4:47 PM (almost 5 hours after the 12:00 PM dose was due)
5. 8/29/2012 - no 12:00 PM dose given
6. 8/29/2012 - 4:00 PM (2 hours before the 6 PM dose was due)
7. 8/30/2012 - 2:46 PM (almost 3 hours after the 12 PM dose was due)
8. 9/1/2012 - no 12 PM dose given
9. 9/2/2012 - no 12 PM dose given
10. 9/5/2012 - no 6:00 AM dose given

An interview was conducted on 9/1/2012 in the afternoon with the Nurse Manager and the Chief Clinical Officer who confirmed the doses were not administered as prescribed. The facility was offered an opportunity to provide explanation regarding the staff failure to adhere to the physician's prescription however as of the exit conference the facility had not provided explanation.


2) Review of the clinical record for Patient # 8, revealed physician orders for the patient to receive Prednisone 20 mg twice daily. Review of the MAR failed to provide evidence the staff administered the 9/01/2012 dose at 7:16 PM. Further review revealed the nurse documented the dose was not given because the medication was not available.

An interview was conducted with the Nurse Manager, on 9/07/2012 at 3:31 PM, who confirmed there is no documentation regarding the missed dose on 9/01/2012 and there is no follow up indicating if pharmacy was contacted nor if the physician was contacted regarding the missed dose.