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Based on record review, and staff interview, for 4 of 8 patients, (Patients #1, 2, 3, and 4), it was determined the governing body failed to ensure the medical staff:

1. followed policies and procedures, and standards of practice for writing complete orders for medication administration.

2. provided clear instructions for the administration of prn medications when ordering more than one prn medication for the same reason.

Findings include:

Review of Rules and Regulations of the Medical Staff of Copper Queen Community Hospital included: "The practitioner's orders must be written clearly, legibly and completely with date and time. Orders which are illegible or improperly written will not be carried out until rewritten by the physician."

1. A review of Patient #1's clinical record revealed the following physician orders:

Date/Time of Order/Order:
8/19/2013 at 7:34 p.m.: Hydromorphone (Dilaudid) injectable 0.5 mg "prn q4h" (as needed every 4 hours). Hydromorphone is classified as an opioid analgesic.

8/22/2013 at 4:36 p.m.: Tramadol tab 50 mg "prn q6h" (as needed every 6 hours) via gastrostomy tube. Tramadol is classified as a synthetic, centrally active analgesic.

8/22/2013 at 4:38 p.m.: Dicyclomine (Bentyl) cap 10 mg "prn bid" (as needed two times a day) via gastrostomy tube. Dicyclomine is classified as an anticholinergic, antimuscarinic medication.

8/25/2013 at 9:52 p.m.: Hydromorphone (Dilaudid) injectable 1 mg "prn q6h" (as needed every 6 hours)

The above "prn" orders were not complete with clear, concise directions for the reason the medications were to be given.

A review of Patient #2's clinical record revealed a physician order dated 5/28/2013 at 11:26 a.m. for "Oxycodone 10 mg by mouth "prn q4H" (as needed every 4 hours). The physician's order did not include the reason for the medication to be administered. Oxycodone is an opioid analgesic usually prescribed for moderate to severe pain. A review of the Medication Record revealed 9 doses of oxycodone were administered during the patient's hospitalization, and the reason documented was "pain." However, 1 dose of oxycodone was administered on 6/2/2013 at 1:18 a.m., and the reason was "anxiety."

Patient #3's clinical record included the following physician orders:
6/4/2013 at 11:11 am.: Oxycodone/Acetaminophen Tab (Percocet), 2 tables "prn q4h" (as needed every four hours)

6/5/2013 at 2:23 p.m.: Hydromorphone (Dilaudid) injectable, 1 mg "prn q4h" (as needed every four hours)

6/5/2013 at 6:08 p.m.: Promethazine injectable, 12.5 mg "prn q6h" (as needed every four hours)

6/5/2013 at 6:08 p.m.: Morphine injectable, 2.5-5 mg "q 10 min prn" (every 10 minutes as needed)

The above "prn" orders were not complete with clear, concise directions for the reason the medications were to be given.

Patient #4's clinical record included the following physician orders:
6/10/2013 at 7:06 a.m.: Alprazolam tab 0.5 mg "prn bid" (as needed two times a day). Alprazolam is classified as a benzodiazepine used to treat anxiety.

6/10/2013 at 5:55 p.m.: Lorazepam tab 0.5 mg "prn tid" (as needed three times a day). Lorazepam is classified as a benzodiazepine used to treat anxiety.

6/10/2013 at 8:48 p.m.: Oxycodone tab 2.5 mg "prn q4h" (as needed every 4 hours).

6/10/2013 at 9 p.m.: Lorazepam tab 1 mg "prn tid" (as needed three times a day).

The above "prn" orders were not complete with clear, concise directions for the reason the medications were to be given.

2. Patient #2's clinical record had physician orders for the following medications:
Date/Time of Order/Order:
5/28/2013 at 11:26 a.m.: Acetaminophen 650 mg by mouth as needed every four hours for temperature greater than 100.5 or "discomfort."

5/28/2013 at 11:26 a.m.: Oxycodone 10 mg by mouth as needed every four hours (reason not documented by physician).

5/29/2013 at 9:45 a.m.: Ketorolac injectable 15 mg intravenous push as needed every four to six hours as needed for pain or fever.

Patients #1, 3, and 4 also had more than one physician orders for medications to be administered for the same reason

The hospital had no policy and procedure that addressed physicians ordering more than one prn medication for the same indication and/or ordering the same prn medications with different doses and frequencies.

During interviews with nursing staff, it was reported that physician's do not always clarify multiple as needed pain medication orders; and the nursing staff would use their own discretion on which medication to use. The Pharmacist also acknowledged during an interview on 8/27/2013, that the physicians were not consistent in writing complete orders, and clear and concise "prn" medication orders.

Based on review of clinical records, review of hospital policies and procedures, and staff interviews, it was determined the hospital failed to develop and implement patient care policies for the pharmacist to ensure physician orders for as needed medications were complete for the reason the medication was to be administered; and to ensure when multiple physician orders for as needed medications were ordered for the same reason, the orders were clear and concise.

Findings include:

Refer to Tag C0241. The hospital's patient care policies for the provision of pharmaceutical services did not include the pharmacist's role in ensuring all physician orders were reviewed for being complete, concise and accurate.

The pharmacist acknowledged during an interview on 8/27/2013 that the physicians were not consistent in writing orders for as needed medications, that included the reason for the medication to be administered. He reported that the clarification of incomplete or unclear orders were mainly the responsibility of the nursing staff.