HospitalInspections.org

Based on record reviews and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient as evidenced by failing to obtain a physician's order before administering a medication to a patient for 1 (#2) of 5 (#1-#5) patients reviewed.

Findings:

Review of the hospital's policy titled "Medications" revealed in part, the hospital will ensure that all medications related to the patient's inpatient stay are ordered, dispensed, labeled, stored, transcribed, administered, and documented in the medical record in accordance with Federal and State Law and industry best practices.

Review of Patient #2's medical record revealed an admission date of 09/26/2022 with an admission diagnosis of unspecified dementia with behavioral disturbance. Review of the physician's orders revealed there was no documentation of a physician's order for Atarax. Review of the MAR revealed a handwritten entry of Atarax (Hydroxyzine) 25 mg PO Q6hrs PRN for anxiety. Review of the Medication First Dose Response & PRN Medication Record revealed on 10/15/2022 at 1:45 a.m., Atarax 25mg PO (up arrow) anxiety was administered to Patient #2. Further review revealed on 10/15/2022 at 2:45 a.m. Patient #2's response was not effective.

In an interview on 12/20/2022 at 11:22 a.m. S1DON confirmed there was no documentation of a physician's order for Atarax in Patient #2's medical record. S1DON verified the medication was administered to Patient #2 on 10/15/2022 at 1:45 a.m. by S2LPN.