HospitalInspections.org

Based on clinical record review, interview and policy review for 2 of 2 patients (Patients #2 and 11) the facility failed to ensure that medications were administered as directed and for one patient (Patient #8) the Medication Administration Record (MAR) failed to reflected documentation of medication refusal. The findings include the following:

a. Patient #2 was admitted on 5/21/19 with a diagnosis of schizophrenia, polysubstance abuse and antisocial personality disorder. The patient had a history of GERD, hypertension, and DM. Review of the physician's orders dated 5/21/19 directed Lisinopril 20 mg daily, hold for a systolic blood pressure (SBP/BP) less than 100 mm of mercury. Review of the MAR indicated that although the patients BP was 80/52 the medication was administered on 5/22/19. There was no adverse outcome documented.

b. Patient #11 was admitted with schizoaffective disorder, Bipolar disorder with a history of congestive heart failure and a cerebral vascular accident. The physicians order dated 5/9/19 directed Hydralazine 25 mg three times a day hold for a SBP of less than 110. Review of the MAR with the Nurse Manager on 6/4/19 at 12:45 PM indicated that although the medication had been administered three times a day for the period of 6/1/19 through 6/3/19 (9 doses) documentation indicated that the patient's blood pressure had been monitored on only 5 occasions.

c. Review of Patient #8's physician orders directed 10/30/18 directed Engerix 1 mg for three doses and MMR booster 0.5 ml times one dose. Review of the MAR on 6/4/19 with the Manager at 12:00 PM identified that the medication orders directed to chart refusals and when offered. Although review of the nursing notes dated 9/19/18, 9/27/18, 10/3/18, 11/6/18, 11/26/18, 2/8/19, 3/13/19, and 5/17/19 identified that the patient was offered and refused the vaccines, review of the May 2019 and June 1-4, 2019 MAR's lacked documentation of offer and/or refusal of the medication.

Review of the Medication Administration and Storage policy indicated that patients can expect to receive medications correctly by the nurse who follows the procedure for preparation and administration. The policy indicated that omitted medications will be clearly noted on the MAR with circled initials and a progress note with an explanation.