HospitalInspections.org

Based on medical records reviews, document reviews, policies reviews and staff interviews, it was determined the facility failed to ensure that the nursing staff documented medications that were administered. This was found in 4 of 10 medical records (MR) reviewed. This was found in MR #1, MR #3, MR #7 and MR #10.

Findings include:

Nursing Staff #11, who is a registered nurse, failed to document on the electronic medication administration record (eMAR) that narcotics were administered.

1. A review of medical record #1 (patient #1) on March 4, 2015 revealed the patient was admitted to the facility on October 1, 2014 with a diagnosis of Dehydration. The patient's previous medical history included Chronic Hematuria and Cancer of the Rectum, Bladder and Prostate which had spread to the bone. On October 1, 2014 at 11:19 PM a physician prescribed Morphine Sulfate extended release (XR) 100 milligrams (mg) orally every 12 hours.

A review of a narcotic report revealed Staff #11 removed three 30 mg tablets of the drug at 11:06 PM on October 2, 2014. A review of the medical record on March 4, 2015 revealed that there was no documentation on the eMAR that this dose was administered.

2. A review of medical record #3 (patient #3) on March 6, 2015 revealed the patient was admitted to the facility on December 27, 2014 with a diagnosis of Rectal Abscess with pain assessed as 10 on a scale of 0 (no pain) to 10 (most severe pain).

A review of the retrospective data obtained from the Pyxis (a brand of an automated dispensing cabinet or ADC - a computerized drug storage device or cabinet designed for hospitals which allow medications to be stored and dispensed near the point of care while controlling and tracking drug distribution) revealed Staff #11 removed 2 mg of Dilaudid injection on December 30, 2014 at 11:07 PM. A review of the medical record revealed that there was no documentation on the eMAR that the drug was administered.

3. A review of patient #7's medical record on March 9, 2015 revealed this seventy-three year old patient was admitted to the facility on December 25, 2014 with complaints of a Gout attack in his left shoulder. A physician ordered Percocet 2 tablets 3 times each day whenever necessary for severe pain (7-10).

A review of the facility documents revealed Staff #11 removed 2 tablets of Percocet on January 3, 2014 at 2:31 AM and 2 tablets of the drug on January 4, 2014 at 7:55 PM. There was no documentation on the eMAR that these doses were administered.

4. A review of MR #10 on March 9, 2015 revealed this eighty-four year old patient was admitted to the facility on January 15, 2015 for a Laproscopic Cholecystectomy that day. A physician prescribed Dilaudid 1 mg every 4 hours as needed for moderate pain (4-6). Staff #11 removed the drug from the Pyxis on January 15, 2015 at 11:29 PM, but there was no documented evidence on the eMAR that she had given the patient this dose.

A review of the facility's policy titled "Medication Safety", which was last reviewed 11/13, revealed "After administration of medication, documentation is completed on the eMAR as 'Mark as Done'".

During staff interviews conducted on March 4, 2015 at approximately 11:30 AM, Staff #1 the Director of Performance Improvement stated that Staff #11 did not document on the eMAR that these medications that she had withdrawn from the Pyxis had been administered.