HospitalInspections.org

Based on review of hospital policies/procedures, medical records, hospital documents and interviews, it was determined that the hospital failed to provide an organized nursing service 24-hours per day to assess patients' care needs and assign, deliver and supervise the care required by each patient as evidenced by:

(395) failing to require that a Registered Nurse (RN) evaluate the pain management of 2 0f 2 patients (Pts #1 & 2);

(397) failing to require that an RN assign the nursing care of each patient to qualified nursing staff; and

(405) failing to require that nursing staff administer medications according to practitioners' orders.

The cumulative effect of these systemic problems resulted in the hospital's failure to provide an adequate, organized nursing service.

Based on review of hospital documents and interview, it was determined that the hospital failed to evaluate the quality of each contracted service in order to ensure that the service is provided in a safe and effective manner.

Findings include:

Review of hospital documents revealed a list of contracted services provided by various individuals and/or agencies. The hospital was unable to provide documentation of evaluation of the services provided under these contracts/agreements.

The Chief Nursing Officer confirmed during an interview conducted on 5/29/14, that the hospital did not have documentation of evaluation of the services provided by any of the contracted agencies/individuals.

Based on review of the hospital's Bylaws of the Medical Staff, Medical Staff Rules and Regulations, policy/procedure, medical record and interview, it was determined that the hospital failed to enforce the requirement that a physician"s orders be clear, complete and properly written for 1 of 1 patient who received titrated medications for sedation (Pt # 12).

Findings include:

Review of the hospital document titled Bylaws of the Medical Staff revealed: "...The purposes of the Medical Staff are:...To provide a structure through these Bylaws, Rules and Regulations, and related manuals which defines the responsibility, authority, and accountability of each organized component and individual Member of the Medical Staff...Responsibilities. To accomplish the above purposes, it is the obligation and responsibility of the medical Staff:...To develop, administer, recommend amendments to and enforce compliance with these Bylaws, its supporting manuals and the Rules and Regulations of the Staff, and with the Hospital bylaws and policies...."

Review of the hospital's Medical Staff Rules and Regulations revealed: "...a member of the medical staff shall be responsible for the medical care and treatment of each patient in the hospital, for the prompt completeness and accuracy of those portions of the medical record for which he is responsible...Orders that are...improperly written will not be carried our until rewritten or clarification of the order is obtained to ensure understanding of the order and to facilitate appropriate follow through of the order...."

Review of hospital policy titled Continuous Sedation in the ICU (Intensive Care Unit) revealed: "...Intravenous sedatives and/or analgesics may be used for short-term continuous sedation for patients in the Intensive Care Unit who require this method of medical intervention...Procedure: obtain orders from the Physician...Specific Physician orders will include: Dosage...Target level of desired sedation according to the following modified Ramsey Scale (RSS)...titration parameters...Utilize an infusion pump to administer the ordered medication and to titrate the dose according to patient's level of sedation...."

Review of Pt # 12's medical record revealed:

On 4/20/14, at 1046, Physician # 43 electronically entered an order for Midazolam: "...titrate per order...start at 2 mg per hour IV, adjust infusion by 1 mg every 20 minutes to sedation goal, max 7 mg per hour...RSS sedation level: 4...."

On 4/20/14, at 0953, an RN documented that Pt # 12 arrived in the ICU. Pt # 12 was intubated and receiving titrated sedation upon arrival to the ICU.

Nursing documented titration of Midazolam as follows:

4/20/14, at 0953: 15mg/hr...RSS sedation level: 4;
4/20/14, at 1900: 15 mg/hr...RSS sedation level: 4;
4/22/14, at 0700: 5 mg/hr...RSS sedation level: 4;
4/23/14, at 0115: 5 mg/hr...RSS sedation level: 4;
4/23/14, at 0700: 5 mg/hr...RSS sedation level 4;
4/25/14, at 1441: 15 mg/hr...RSS sedation level: 1;
4/25/14, at 2000: 15 mg/hr...RSS sedation level: 1;
4/26/14, at 2200: 5 mg/hr...RSS sedation level: 1;
4/26/14, at 2230: 10mg/hr...RSS sedation level: 1; and
4/26/14, at 2300 through 4/17/14, at 0500: 10 mg/hr...RSS sedation level: 3.

ICU RN # 16 confirmed, during interview conducted on 5/28/14, that Pt # 12 arrived at the hospital with a Midazolam drip running at 15 mg/hr. Nursing would have been unable to titrate the Midazolam down to the starting dose which Physician # 43 ordered and maintain the sedation level of 4 as ordered. The physician's order was not specific to the individual care needs of Pt #12 for a starting dose or maximum dose.

On 4/20/14, at 1048, Physician # 43 electronically entered an order for Fentanyl: "...TITRATE PER ORDERS...50 mcg per hour IV, adjust infusion by 10 mcg per hour every 10 minutes until target sedation level is reached, max 250 mcg per hour...."

Nursing documented titration of Fentanyl as follows:

4/20/14, at 1100: 100 mcg/hr;
4/20/14, at 1300: 150 mcg/hr;
4/20/14, at 1900: 150 mcg/hr...RSS sedation level 4;
4/22/14, at 0700: 150 mcg/hr...RSS sedation level 4;
4/22/14, at 1000: 200 mcg/hr...RSS sedation level 1; and
4/22/14, at 1945: 200 mcg/hr...RSS sedation level 1.

ICU RN # 16 confirmed, during interview conducted on 5/28/14, that Pt # 12 arrived at the hospital with a Fentanyl drip running at 100 mcg/hr. Physician # 43's order for Fentanyl was not specific to the individual care needs of Pt # 12 for a starting dose of Fentanyl.

Based on review of hospital policy/procedure, medical records and interview, it was determined that the hospital failed to require that a Registered Nurse (RN) evaluate the pain management of 2 of 2 patients (Pts # 1 and 2), by assessing the patients' ability to use a pain rating scale and assess the patients' personal goals for pain relief as required by hospital policy .

Findings include:

Review of hospital policy/procedure titled Pain Assessment, Reassessment and Management revealed: "...It is the policy of this organization to respect and support the patient's right to optimal pain assessment and management...Effective pain assessment and management can remove the adverse psychological and physiological effects of unrelieved pain. Optimal management of the patient experiencing pain enhances healing and promotes both physical and psychological wellness...Assess for presence of pain for all patients:..Assess patient's ability to use a pain rating scale and patient's personal goal for pain relief...."

Review of Pt # 1's medical record revealed:

A physician wrote an order on 5/17/14 at 1900 for 1 mg Dilaudid IV q 3h prn Pain 1-10.

On 5/17/14 at 2157, an RN administered 1mg of Dilaudid IVP. S/he recorded the Pt's pre-medication pain score as 7 and post-medication pain score as 6. The medical record did not contain documentation of notification of the physician for further orders or documentation of other actions for pain relief.

On 5/18/14 at 0105, an RN administered 1 mg of Dilaudid IVP. S/he recorded the Pt's pre-medication pain score as 7 and post-medication pain score as 6. The medical record did not contain documentation of notification of the physician for further orders or documentation of other actions for pain relief.

Pt # 1's medical record did not contain documentation of his ability to use the pain rating scale or his personal goal for pain relief.

Review of Pt # 2's medical record revealed:

On 5/18/14, at 1948, a physician electronically entered an order for Hydromorphone (Dilaudid) 1 mg IVP (Intravenous Push) q 1 h (every hour) as needed for pain scores of 1-4 (Using a pain scale of 1-10, where 10 is the most severe pain).

On 5/18/14 at 1956, a physician electronically entered an order for Hydrocodone (Vicodin) q 4h po (by mouth) prn for pain scores of 1-5.

On 5/18/14, at 1957, a physician electronically entered an order for Morphine 4 mg IVP q 2 h as needed for pain of 1-10.

An RN documented administration of medication for pain:

Dilaudid 1 mg IVP, on 5/18/14, at 2010. Pt's pain score pre-medication: 07 and post-medication: 04;
Dilaudid 1 mg IVP, on 5/18/14, at 2217. Pt's pain score pre-medication: 07 and post-medication: 04;
Dilaudid 1 mg IVP, on 5/19/14, at 0028. Pt's pain score pre-medication: 07 and post-medication: 04;
Dilaudid 1 mg IVP, on 5/19/14, at 0144. Pt's pain score pre-medication: 07 and post-medication: 04;
Morphine 4 mg IVP on 5/19/14, at 0357. Pt's pain score pre-medication: 07 and post-medication: 05; and
Morphine 4 mg IVP on 5/19/14, at 0607. Pt's pain score pre-medication: 08 and post-medication: 06.

Nursing did not document actions taken for further pain relief or notification of the physician, or documentation that the patient was satisfied with the results of the medication.

Pt #2's medical record did not contain documentation of his ability to use the pain rating scale or his personal goal for pain relief.

RN # 9 confirmed during chart review conducted on 5/23/14, that nursing did not follow the hospital's policy/procedure related to pain assessment and management. Nursing did not document the patients' ability to utilize the pain rating scale or their personal goals for pain relief.

Based on interview and review of medical record and hospital documents, it was determined that the hospital failed to require that an RN assign the nursing care of a patient who was located in the Intensive Care Unit for 1 of 1 patient (Pt # 12).

Findings include:

RN # 19 explained the use of the Daily Acuity Assignment sheets during interview conducted on 5/27/14. S/he explained that each patient's care needs are assessed by an RN according to the hospital's patient acuity plan. The patients are listed on the assignment sheet with their acuity ratings. Nurses are assigned to the patients based on the patients' acuity ratings/care needs. The nurses' names are written next to the patients' names to indicate which nurse is responsible for each individual patient's care.

Review of Pt # 12's medical record revealed that he was admitted directly to the hospital Intensive Care Unit (ICU) on 4/20/14, at 0953. The patient was intubated and on a ventilator from 4/20/14, until he was extubated on 4/28/14 at 1140, and discharged on 4/30/14.

Review of the Inpatient Daily/Night Acuity Assignment sheets for 4/20/14 through 4/30/14 revealed:

Pt # 12's name was written on the Day Shift and Night Shift assignment sheets from 4/20/14 through 4/24/14 with the RNs' names responsible for his care recorded beside the patient's name.

The Day Shift and Night Shift assignment sheets for 4/25/14 did not contain Pt # 12's name.
The Night Shift assignment sheets for 4/26/14 and 4/27/14, did not contain Pt # 12's name.

The Chief Nursing Officer confirmed, during interview conducted on 5/29/14, that she was unable to provide documentation of the RN assigned to provide care for Pt # 12 during the shifts listed above when the patient was located in the hospital's ICU.

Based on review of hospital policies/procedures, medical records and interviews, it was determined that the hospital failed to require that medication be administered in accordance with the practitioners' orders as evidenced by:

1. failing to administer intravenous (IV) pain medication according to the practitioner's order for 1 of 2 patients who received IV pain medication (Pt # 2); and

2. failing to administer titrated medications for sedation according to the practitioner's orders for 1 of 1 patient (Pt # 12); and

3. failing to administer medication for alcohol withdrawal as ordered per protocol for 1 of 1 patient (Pt # 12).

Findings include:

1. Review of hospital policy/procedure titled Safe Medication Practices revealed: "...Confirm the following six (6) "Rights" each time a medication is administered...Right Medication:...Check the medication order...Right Dose: Re-check any dosage calculations and verify with the physician if the order is illegible or incomplete...."

Review of Pt # 2's medical record revealed:

On 5/18/14, at 1948, a physician electronically entered an order for Hydromorphone (Dilaudid) 1 mg IVP (Intravenous Push) q 1 h (every hour) as needed for pain scores of 1-4 (Using a pain scale of 1-10, where 10 is the most severe pain).

On 5/18/14, at 1957, a physician electronically entered an order for Morphine 4 mg IVP q 2 h as needed for pain of 1-10.

An RN documented administration of medications:

Dilaudid 1 mg IVP, on 5/18/14, at 2010. Pt's pain score pre-medication: 07 and post-medication: 04;
Dilaudid 1 mg IVP, on 5/18/14, at 2217. Pt's pain score pre-medication: 07 and post-medication: 04;
Dilaudid 1 mg IVP, on 5/19/14, at 0028. Pt's pain score pre-medication: 07 and post-medication: 04;
Dilaudid 1 mg IVP, on 5/19/14, at 0144. Pt's pain score pre-medication: 07 and post-medication: 04;
Morphine 4 mg IVP on 5/19/14, at 0357. Pt's pain score pre-medication: 07 and post-medication: 05;
Morphine 4 mg IVP on 5/19/14, at 0607. Pt's pain score pre-medication: 08 and post-medication: 06;
Dilaudid 1 mg IVP on 5/19/14, at 0814. Pt's pain score pre-medication: not recorded and post-medication:
03;
Dilaudid 1 mg IVP on 5/19/14, at 1119. Pt's pain score pre-medication: 6 and post-medication: 3.5;
Dilaudid 1 mg IVP on 5/19/14, at 1355. Pt's pain score pre-medication: 5 and post-medication: 3;
Dilaudid 1 mg IVP on 5/19/14, at 1558. Pt's pain score pre-medication: 5-6 and post-medication: 4; and
Dilaudid 1 mg IVP on 5/19/14, at 1813. Pt's pain score pre-medication; 5 and post-medication: 3.

The Director of Pharmacy confirmed, during interview conducted on 5/23/14, that the Morphine should have been administered for pain prior to use of the Dilaudid due to the order for Morphine for a score of 1-10 and the patient's scores pre-medication higher than 4. In addition, Dilaudid is a more potent pain medication and should be used after determining that the Morphine was ineffective. The orders required clarification by nursing and/or pharmacy, since Dilaudid is the more potent drug and was ordered for lower pain scores.

RN # 9 confirmed that Pt # 2's pain scores post-medication were frequently in the range to warrant another dose of medication per order and/or contact with the physician for clarification. S/he confirmed that the medical record did not contain documentation that nursing contacted the physician to clarify the orders for pain management.

2. Review of hospital policy titled Continuous Sedation in the ICU (Intensive Care Unit) revealed: "...Intravenous sedatives and/or analgesics may be used for short-term continuous sedation for patients in the Intensive Care Unit who require this method of medical intervention...Procedure: obtain orders from the Physician...Specific Physician orders will include: Dosage...Target level of desired sedation according to the following modified Ramsey Scale (RSS)...titration parameters...Utilize an infusion pump to administer the ordered medication and to titrate the dose according to patient's level of sedation...."

Review of Pt # 12's medical record revealed:

On 4/20/14, at 1046, Physician # 43 electronically entered an order for Midazolam: "...titrate per order...start at 2 mg per hour IV, adjust infusion by 1 mg every 20 minutes to sedation goal, max 7 mg per hour...RSS sedation level: 4...."

On 4/20/14, at 0953, an RN documented that Pt # 12 arrived in the ICU.

Nursing documented titration of Midazolam as follows:

4/20/14, at 0953: 15mg/hr...RSS sedation level: 4;
4/20/14, at 1900: 15 mg/hr...RSS sedation level: 4;
4/22/14, at 0700: 5 mg/hr...RSS sedation level: 4;
4/23/14, at 0115: 5 mg/hr...RSS sedation level: 4;
4/23/14, at 0700: 5 mg/hr...RSS sedation level 4;
4/25/14, at 1441: 15 mg/hr...RSS sedation level: 1;
4/25/14, at 2000: 15 mg/hr...RSS sedation level: 1;
4/26/14, at 2200: 5 mg/hr...RSS sedation level: 1;
4/26/14, at 2230: 10mg/hr...RSS sedation level: 1; and
4/26/14, at 2300 through 4/17/14, at 0500: 10 mg/hr...RSS sedation level: 3.

ICU RN # 16 confirmed, during interview conducted on 5/28/14, that nursing did not follow the physician orders for titration of Midazolam. Pt # 12 arrived at the hospital with a Midazolam drip running at 15 mg/hr. Nursing would have been unable to titrate the Midazolam down to the starting dose which the physician ordered. Nursing did not obtain an order which would have been specific to Pt #12 for a starting dose upon patient arrival to the hospital. Nursing did not follow the starting dose, exceeded the maximum dose and did not follow the orders for adjustment of infusion. Nursing did not obtain another order.

On 4/20/14, at 1048, Physician # 43 electronically entered an order for Fentanyl: "...TITRATE PER ORDERS...50 mcg per hour IV, adjust infusion by 10 mcg per hour every 10 minutes until target sedation level is reached, max 250 mcg per hour...."

Nursing documented titration of Fentanyl as follows:

4/20/14, at 1100: 100 mcg/hr;
4/20/14, at 1300: 150 mcg/hr;
4/20/14, at 1900: 150 mcg/hr...RSS sedation level 4;
4/22/14, at 0700: 150 mcg/hr...RSS sedation level 4;
4/22/14, at 1000: 200 mcg/hr...RSS sedation level 1; and
4/22/14, at 1945: 200 mcg/hr...RSS sedation level 1.

ICU RN # 16 confirmed, during interview conducted on 5/28/14, that nursing did not follow the physician orders for titration of Fentanyl. Pt # 12 arrived at the hospital with a Fentanyl drip running at 100 mcg/hr. Nursing did not obtain an order specific to Pt # 12 for a starting dose upon patient arrival to the hospital. Nursing did not follow the starting dose and RN # 16 was unable to provide documentation of adjustment of the infusion rate to determine whether nursing followed the the physician order for rate of infusion when titrating up or down.

3. Review of hospital order form titled Physician's Orders Alcohol Withdrawal Protocol revealed "Dosing Scales" for administration of Lorazepam (Ativan) according to a patient's severity of alcohol withdrawal symptoms. A physician marks a box to indicate whether the RN is to administer Lorazepam according to the "High Dose Scale" or "Low Dose Scale". The physician can enter the orders into the patient's medical record via an electronic order set which corresponds to the form. The High Dose Scale contains the following orders: Severity Score of 12 or higher requires IV administration of 6 mg of Ativan; Score of 10-11 requires IV administration of 5 mg of Ativan; Score of 8-9 requires IV administration of 4 mg of Ativan; Score of 6-7 requires IV administration of 3 mg of Ativan; Score of 0-5 requires no Ativan.

The Protocol also contained the following orders: "...Continue to assess 30 minutes after each dose. Once score is 6 or less, resume monitoring every 2 hours while awake and every 4 hours during sleep...."

Review of Pt # 12's medical record revealed:

Pt # 12 was intubated and on a ventilator with titrated medication for sedation from 4/20/14, until he was extubated on 4/28/14.

A physician ordered the High Dose Scale of the Alcohol Withdrawal Protocol for administration of Ativan on 4/20/14, at 1512.

On 4/20/14, at 2000, an RN documented a Severity Score of 7 and did not administer the required 3 mg of Ativan. The RN did not document rationale for the omission.

On 4/21/14, at 0058, an RN documented a Severity Score of 5 and no Ativan was required or administered.

On 4/21/14, at 0113, an RN administered 1 mg of Ativan IV. The medical record did not contain documentation of a Severity Score or an order for 1 mg of Ativan.

On 4/21/14, at 0130, an RN documented a Severity Score of 5 and no Ativan was required or administered. The next assessment was required on 4/21/14, at 0530 per protocol. The RN documented the next assessment on 4/21/14 at 2135.

On 4/22/14, at 0408, an RN documented a Severity Score of 8 and administered the required 4 mg of Ativan. The RN reassessed the patient at 0430, with a Severity Score of 3. The RN documented assessment of the patient at 0700 with a Severity Score of 2. The next assessment was required on 4/22/14, at 1100 per protocol. The RN documented the next assessment on 4/23/14 at 0321. The patient's Severity Score at that time was 8 and the RN administered the required 4 mg of Ativan. A reassessment was required at 0351 (30 minutes after administration of the medication). The next assessment was required 4 hours later, at 0751. The RN did not document an assessment of the patient for alcohol withdrawal symptoms until 4/23/14, at 0900.

An RN documented administration of 1 mg of Ativan IV on 4/23/14, at 1100. The medical record did not contain documentation of the patient's withdrawal symptoms at that time and did not contain an order for administration 1 mg of Ativan. The RN recorded the patient's next assessment on 4/23/14 at 2000.

RN # 16 confirmed, during interview conducted on 5/28/14, that nursing did not perform and document the alcohol withdrawal assessments as required by protocol and did not follow the orders for administration of Ativan as required by protocol. S/he also confirmed that nursing administered Ativan without an order on 4/21/14 and 4/23/14.

Based on review of Bylaws of the Medical Staff, medical record and interview, it was determined that the hospital failed to require an accurately written medical record for 1 of 1 patient who underwent a colectomy with colostomy (Pt # 2).

Findings include:

Review of the hospital's Bylaws of the Medical Staff revealed: "...Medical Records...Required Consent: The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient. The record shall include:...Operative/special procedure reports, including the name of the surgeon and assistants...Evidence and documentation of appropriate informed consent...."

Review of Pt # 2's medical record revealed an informed consent form for Colectomy with Colostomy, signed by the patient for surgery on 5/21/14. The consent form contained the surgeon's name (Physician # 28) and the name of the "Assistant" for surgery (PA Student # 35). Review of the Operative Report completed by Physician # 28 revealed that it contained documentation of an "Assistant" during the operative procedure. The Assistant listed was PA Student # 35.

Employee # 18 confirmed during record review conducted on 5/23/14, that the PA Student # 35 was listed on the surgical consent as an assistant during surgery.

The OR Clinical Manager confirmed during interview conducted on 5/29/14, that the PA Student observed Pt # 2's surgical procedure and did not function as an assistant.

Based on review of hospital policy/procedure, medical record and interview it was determined that the hospital failed to require that pharmaceutical services meet the needs of patients as evidenced by:

1) failing to clarify pain medication orders which were not in accordance with the hierarchy for pain medications required by policy/procedure for 1 of 2 patients (Pt # 2).

This citation does NOT raise to condition level.

Findings include:

Review of hospital policy/procedure titled Pain Scales-Clarification; Department: Pharmaceutical Services revealed: "...It is the policy of this hospital to clarify and or include pain scales and or hierarchies when multiple pain medications are ordered...To be utilized when pain scales are not indicated by the physician...Two different Pain medications, both injectable...If both are narcotics, the less potent narcotic use for pain scale 1-5 and the more potent narcotic for pain scale 6-10...The hierarchy for the pain scales follows the logic below:...Narcotic Pain medications: for Moderate to severe pain scales and given a hierarchy based on potency...Call physician for further clarification...."

Review of Pt # 2's medical record revealed:

On 5/18/14, at 1948, a physician electronically entered an order for Hydromorphone (Dilaudid) 1 mg IVP (Intravenous Push) q 1 h (every hour) as needed for pain scores of 1-4 (Using a pain scale of 1-10, where 10 is the most severe pain).

On 5/18/14, at 1957, a physician electronically entered an order for Morphine 4 mg IVP q 2 h as needed for pain of 1-10.

An RN documented administration of medications:

Dilaudid 1 mg IVP, on 5/18/14, at 2010. Pt's pain score pre-medication: 07 and post-medication: 04;
Dilaudid 1 mg IVP, on 5/18/14, at 2217. Pt's pain score pre-medication: 07 and post-medication: 04;
Dilaudid 1 mg IVP, on 5/19/14, at 0028. Pt's pain score pre-medication: 07 and post-medication: 04;
Dilaudid 1 mg IVP, on 5/19/14, at 0144. Pt's pain score pre-medication: 07 and post-medication: 04;
Morphine 4 mg IVP on 5/19/14, at 0357. Pt's pain score pre-medication: 07 and post-medication: 05;
Morphine 4 mg IVP on 5/19/14, at 0607. Pt's pain score pre-medication: 08 and post-medication: 06;
Dilaudid 1 mg IVP on 5/19/14, at 0814. Pt's pain score pre-medication: not recorded and post-medication:
03;
Dilaudid 1 mg IVP on 5/19/14, at 1119. Pt's pain score pre-medication: 6 and post-medication: 3.5;
Dilaudid 1 mg IVP on 5/19/14, at 1355. Pt's pain score pre-medication: 5 and post-medication: 3;
Dilaudid 1 mg IVP on 5/19/14, at 1558. Pt's pain score pre-medication: 5-6 and post-medication: 4; and
Dilaudid 1 mg IVP on 5/19/14, at 1813. Pt's pain score pre-medication; 5 and post-medication: 3.

The Director of Pharmacy provided the above policy/procedure related to "Pain Scale Clarification" on 5/23/14, and explained that it was developed for situations when the physician had not specified the pain scale. However, she explained that the hierarchies are relevant even when the physician indicates the pain scale. She confirmed, during interview conducted on 5/23/14, that the Morphine should have been administered for pain prior to use of the Dilaudid due to the order for Morphine for a score of 1-10 and the patient's scores pre-medication higher than 4. In addition, Dilaudid is a more potent pain medication and should be used after determining that the Morphine was ineffective. The orders required clarification by nursing and/or pharmacy, since Dilaudid is the more potent drug and was ordered for lower pain scores. She confirmed that pharmacy did not clarify the order.