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Based on observation, record review and staff interview, the facility failed to administer the correct dosage of medication ordered by the physician for 1( #3) of 5 patients observed during medication pass.

The findings include:

Observation of medication pass for Patient #3 on 8/5/13 at 10:45AM reveals that Employee #1 engaged Patient #3 in conversation when they approached the window of the medication room for their morning medication. Patient #3 stated that she needed her eyedrops this morning. Patient #3 was given a new bottle of Ketotifen Fumarate (Zaditor) opthalmic eyedrops by the nurse to self-administer the medication. Patient#3 struggled to open the bottle. The nurse asked Patient #3 if she needed help to open the bottle of eyedrops and she removed the secured tape from the neck of the eyedrop bottle. Patient #3 was standing at the window of the medication room and Employee #1 asked the patient to turn around and to hold her head backwards for her eyedrops. Employee #1 squeezed 4 drops of Ketotifen Fumarate (one drop after the other) into the patient's left eye and one drop into the right eye.

Review of the physician's orders revealed Zaditor eyedrops 1 drop twice a day to eyes.

Employee #1 was interviewed on 8/5/13 at 11:53AM and she stated that she administered 2 eyedrops to the left eye of Patient #3 because one drop was hung up on the lashes.




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Based on observation, record review and staff interview, the facility failed to obtain a physician's order for self-administered medications for 2 (#2,#10) of 5 patients observed on medication pass.

The findings include:


1. On 8/5/13 at 10:27 am, Patient #2 walked up to the window of the medication room to receive her medications. Employee #1 engages Patient #2 in conversation and stated, "here is your Flonase." Patient #2 took the Flonase and self-administered the medication.

Review of the Medical Record for Patient #2 did not reveal an order for self-administration of medications.

Interview with Employee #2 on 8/6/13 at 11:00AM reveals that she did not realized that you have to have a physician's order for self-administration of medications and did not see anything wrong with it.

Review of the policy for Medication Administration reveals that," upon receiving an order for self-administered medications, the medication will be documented as such in the Medication Administration Record (MAR). Teaching will be documented in the patient education record with an entry regarding patient's response to teaching in the nurse's notes."


2. During observation of Medication pass with Employee #3 on 8/6/13 at 8:51AM, Employee #3 gave Patient #10 three inhalers. The inhalers were Albuterol, Atrovent, Q Varr 80 mcg. There was no instruction or reminders given to Patient #10 as to how to self-administer the inhalers. Patient #10 was also given a bottle of Lidocaine Viscous. Patient #10 took the bottle of Lidocaine Viscous and poured a small amount of liquid into the plastic medication cup to use. Employee #3 stated that Patient #10 brought her inhalers from home. An approximate amount of Nystatin 5 cc was given to Patient #10 to swish and swallow.

Review of the physician's orders revealed Lidocaine Viscous was ordered on 8/4/13 and no dosage amount was noted on the physician's order sheet.

Interview with Employee #3 on 8/6/13 at 9:00 AM revealed that Patient #10 brought her medications from home and no amount was ordered. Employee #3 stated that when there is no amount on the order sheet you would obtain clarification from the doctor. She stated it was in her notes to call the doctor to get an amount.

Based on observation, record review and staff interview, the facility failed to remove expired drugs from stock on 1 of 2 medication rooms.


The findings include:

The medication unit was observed on 8/4/13 at 11:00AM. During observation of the Medication Stocked cart on the Women's Unit, there was 1 box of 69 Vitamin E soft gel capsules with Lot #p-16329 that were expired on 8/1/13. In the same box, there were 2 oyster shell calcium plus Vitamin D 250 mg tablets with NDC # 0904-1882-61 expired on 8/1/13; 2 tablets of Senna Laxative with NDC # 0904-5165-61 that expired on 3/13/13.

Record review of the Medication Room Inspection Reports dated 7/31/13 to 8/4/13 revealed that expired, recalled, deteriorated, broken containers and mislabeled drugs were sent back to the Pharmacy.

Interview with Consultant Pharmacist/Director for Comprehensive Pharmacist Services on 8/6/13 at 11:37AM reveals that they do monthly inspection and get rid of expired medications.