HospitalInspections.org
Bringing transparency to federal inspections
HCA FLORIDA SOUTH SHORE HOSPITAL
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on clinical record review and staff interview it was determined that the Registered Nurse did not ensure patients were assessed prior to administration of medications for allergies for 1 (#1) of 10 sampled patients. This practice does not ensure patient safety and may cause a prolonged hospital stay.
Findings include:
Patient#1's admission assessment dated 7/10/11 at 8:53 p.m. revealed the patient's allergy list. The medication Lorazepam (Ativan) was listed on the allergy list as causing difficulty in breathing and hives.
A review the Medication Administration Record (MAR) dated for 7/15/11 revealed the patient received Ativan 0.5 milligrams (mg) by mouth at 6:47 a.m. and again at 8:37 p.m.
A review of the nursing documentation for 7/15/11 thru 7/16/11 did not reveal any documentation addressing the needs for administering the Ativan or notifying the physician of the known allergy to the medication.
Interview with the Director of Quality on 9/1/11 at approximately 4:00 p.m. confirmed the findings.