HospitalInspections.org

Based on interview and record review, the hospital failed to follow their policy and procedure titled, "Administration of Medication" for one of 19 sampled patient (Patient 25) when:

1. Registered Nurse (RN) 1 documented she administered Fentanyl (a controlled narcotic pain medication) intravenously (IV- medication is given into the vein) 25 micrograms (mcg, a unit of measurement) in Post Anesthesia Care Unit (PACU-recovery nursing care following surgical procedures) to Patient 25 but did not give the medication.

2. RN 3 administered Fentanyl 25 mcg IV to Patient 25 on the medical surgical floor (med surg unit, cares for adult patients with a diverse range of medical conditions), without documenting the medication administration on the medical administration record.

These failures resulted in an inaccurate medication administration record and for the care providers to not have an accurate account of a patient's medication administration which had the potential to lead to under or over medication and poor outcomes.

3. RN 3 administered Fentanyl 25 mcg IV to Patient 25 without a physician order (PO).

This failure resulted in Patient 25 receiving the incorrect IV narcotic pain medication, post operatively, which had the potential for respiratory depression leading to brain damage, coma, even death without a PO.

Findings:

1. During a concurrent interview and record review 4/4/23, at 1:05 PM, with the Chief Nursing Officer (CNO), Patient 25's "Record of Admission," (RA) dated 3/27/23, was reviewed. The "RA" indicated, Patient 25 was 72 years old, and the admitting diagnosis was "Right Hip Ulcer, failed outpatient [treatment]." Patient 25's "PACU Short Stay Record" (PSSR), dated 3/29/23, was reviewed. The "PSSR" indicated, Patient 25 was admitted to PACU at 2:26 PM, after surgery was performed on Patient 25's right hip with a graft [a piece of living tissue transplanted surgically]. CNO stated, The PACU registered nurse (RN 1) documented she administered Patient 25's pain medication, Fentanyl 25 mcg IV, at 2:58 PM in PACU. CNO stated, RN 1 documented Patient 25 was transferred to the med surg floor at 3:10 PM.

During a concurrent interview and record review on 4/4/23, at 2:50 PM, with CNO, Patient 25's "Patient Progress Notes," (PPN) dated 3/29/23, were reviewed. CNO stated, "We don't know the amount of medication given at 3:15 PM, or who gave it. There is no documentation in the chart about it."

During an interview and record review on 4/5/23, at 8:50 AM, with RN 1, Patient 25's "PSSR", dated 3/29/23 was reviewed. RN 1 stated, she worked in PACU and took care of Patient 25 after her surgery on 3/29/23. RN 1 stated, she did not give any pain medication to Patient 25 while Patient 25 was in PACU. RN 1 stated, Patient 25 was transferred to her room at 3:10 PM. RN 1 stated, she heard Patient 25 cry out while transferring back to her med surg room. RN 1 stated, RN 3 ran back to PACU and checked out the Fentanyl from the pyxis (automated medication dispensing system). RN 1 stated, RN 3 gave Patient 25 Fentanyl in her med surg room. RN 1 stated, she documented she gave the Fentanyl to Patient 25 at 2:58 PM on the PACU paperwork, but she did not give did not give the Fentanyl in PACU. RN 1 stated, the Fentanyl was not given to Patient 25 at the time documented on the "PSSR." RN 1 stated, she documented the time the Fentanyl was given as 2:58 PM because that was the time RN 3 checked out the Fentanyl from the PACU pyxis.

During an interview, on 4/5/23, at 2 PM, with CNO, CNO stated, RN 1 documented the Fentanyl 25 mcg was given to Patient 25 by herself in PACU. CNO stated, the Fentanyl 25 mcg administration time (2:58 PM) documented by RN 1, in Patient 25 PACU notes (PSSR), was incorrect.

2. During a concurrent interview and record review on 4/4/23, at 2:40 PM, with RN 4, Patient 25's "Patient Progress Notes," dated 3/29/23, at 3:15 PM, were reviewed, The "PN" indicated, "Pt [patient] retrned [sic] from surgery, calm. Surgery RN gave Fentanyl at the bedside." RN 4 stated, "Yes, the surgery nurse gave my patient pain medication. I don't know her name or the amount of the medication."

During a concurrent interview and record review on 4/4/23, at 2:50 PM, with CNO, Patient 25's "PN," dated 3/29/23, were reviewed. CNO stated, "We don't know the amount of medication given at 3:15 PM, or who gave it. There is no documentation in the chart about it."

During an interview on 4/4/23, at 3:15 PM, with RN 2, RN 2 stated, she helped RN 1 and RN 3 transfer Patient 25 to the med surg floor. RN 2 stated, "After we transferred Patient 25 to her bed, I saw RN 3 give Patient 25 some Fentanyl IV."

During an interview on 4/5/23, at 10:15 AM, with RN 3, RN 3 stated, RN 1 took Patient 25 back to her bed on the med surg floor and she helped with the transfer. RN 3 stated, RN 4 told her Patient 25 did not have pain medication orders. RN 3 stated, she went back to PACU, and pulled out a Fentanyl vial (small bottle). RN 3 stated, she gave 25 mcg Fentanyl IV. RN 3 stated, she did not document the time she gave Patient 25 Fentanyl 25 mcg IV.

During a concurrent interview and record review, on 4/5/23, at 2 PM, with CNO, "Post Anesthesia Recovery Physician Orders" (PACU PO), dated 3/29/23, and Surgeon (MD 3) post operative orders, dated 2/29/23, were reviewed. "PACU PO" indicated, Fentanyl 25 mcg IV ordered for pain. CNO stated, "These anesthesiologist's orders [PACU PO] are not to be followed after any surgical patients has been discharged form PACU." CNO stated, "[MD 3, the surgeon] did not order Fentanyl for this patient post operatively for pain. Therefore [Patient 25] received the wrong medication for pain when she came back to her room." CNO stated, RN 3 gave Patient 25 Fentanyl, in her med surg room, utilizing the anesthesiologist's "PACU PO." CNO stated, RN 3 did not document she gave Patient 25 Fentanyl on the med surg floor.

3. During an interview on 4/5/23, at 10:15 AM, with RN 3, RN 3 stated, RN 1 was taking Patient 25 back to her bed on the med surg floor and she helped with the transfer. RN 3 stated, RN 4 told her Patient 25 did not have post op pain medication orders. RN 3 stated, she went back to PACU, and pulled out a Fentanyl vial. RN 3 stated, she gave 25 mcg Fentanyl IV. RN 3 stated, "I now realize [Patient 25] wasn't a surgical patient any longer. . .once we left surgery department. . .the anesthesiologist's post op orders aren't to be followed."

During a concurrent interview and record review, on 4/5/23, at 2 PM, with CNO, "Post Anesthesia Recovery Physician Orders" (PACU PO), dated 3/29/23, and Surgeon (MD 3) post operative orders, dated 2/29/23, were reviewed. PACU PO indicated, Fentanyl 25 mcg IV ordered for pain. CNO stated, "These anesthesiologist's orders were not to be followed after any surgical patients had been discharged form PACU. These orders are not in the anesthesiologist's respective scope of practice." CNO stated, "[MD 3] did not order Fentanyl for this patient post operatively for pain. So [Patient 25] received the wrong medication for pain when she came back to her room." CNO stated, RN 3 gave Patient 25 Fentanyl in her med-surg room, not the post operative pain medication the surgeon ordered.

During a review of the facility's policy and procedure titled, "Administration of Medication", dated 9/29/22, the "P&P" indicated, "Medication will be administered only upon the order of a member of the medical staff...under the guidelines of their respective scopes of practice...27. Each dose of medication administered is to be properly recorded in the patient's electronic medical record."

During a review of the website registerednursing.org/nclex/medication-administration (a registered nurse professional organization), undated, the website indicated, "Documenting Medications Given Using All Routes" Nurses are legally and ethically responsible and accountable for accurate and complete medication administration, observation, and documentation...All controlled substances are documented on the narcotics record as soon as they are removed, and all controlled substances, like all other medications, are documented on the client's medication record as soon as they are administered...All medications that are given...must be documented in the patient's medication record...Additional professional responsibilities, in terms of medication administration, include the observation and assessment of the patient prior to the administration of a medication and the observation and evaluation of the patient's responses to the medication including the therapeutic effects, any side effects and adverse drug reactions to the medication."