HospitalInspections.org

Based on facility policy review, medical record review, and interviews, the facility failed to administer medications as ordered for one (#3) patient of nine patients reviewed.

The findings included:

Review of the facility's Medication Administration policy (undated) revealed "...provides a system whereby the patient recieves the proper medication at the correct time, dose and route...All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations...and in accordance with the approved medical staff policies and procedures...Medications must be reviewed before administration...Visually confirm the medication against the medication order on the MAR [medication administration record]. This assures you have the right MEDICATION, right TIME, right DOSE..."

Medical record review revealed Patient #3 was born at the facility on 5/3/17 and was discharged home with his mother on 6/12/17. Further review of the discharge summary dated 6/12/17 revealed "...Pregnancy was complicated by short interval, insufficient prenatal care...Hepatitis C positive status [mother]...daily tobacco smoking...use of non-prescribed Marijuana, and use of non-precribed (street) Subutex [medication used to treat opiod dependence/addiction] as well as precribed Subutex...on 6/02/2017, at 4 days postnatal age, because of signs of neonatal abstinence syndrome...was transferred from Mother/Newborn area to the Neonatal Intensive Care Unit...admission drug screen was positive for Cannabinoids [Marijuana]...Because of elevated Finnegan [a system of assessing and scoring drug withdrawal symptoms in infants] drug withdrawal scores, oral Morphine [an opoid type narcotic drug used to reduce withdrawal symptoms in an infant] was started on 6/3/17, weaned as tolerated, and scheduled dosing was stopped on 6/8/17..."

Review of Physician's Progress Notes dated 6/8/17 revealed "...DC [discontinue] Morphine..."

Review of the Medication Administration Record (MAR) revealed on 6/10/17 at 8:43 PM and 11:33 PM Patient #3 was administered Morphine 0.02 mg (milligrams) orally. Further review revealed on 6/11/17 at 2:25 AM the patient was administered Morphine 0.02 mg orally.

Interview with the Nurse Manager and the Nursing Team Leader for the Neonatal Intensive Care Unit (NICU) on 6/20/17 at 11:30 AM, in the Nursing Administrative Conference Room, confirmed the Morphine for Patient #3 was discontinued on 6/8/17. Further interview confirmed the doses administered on 6/10/17 at 8:43 PM and 11:33 PM and the dose administered on 6/11/17 at 2:25 AM were administered without a Physician's order and the facility failed to follow facility policy.