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Based on observation, interview and record review, the hospital failed to have a verified physician order to give an antibiotic for 1 of 30 sampled patients (#9).

Findings:

Patient #9 was observed on 1/26/18 at 11:53 AM sitting up in chair eating his lunch. The patient was receiving intravenous (IV) Normal Saline 0.9%. An empty bag of Ciprofloxacin (Cipro) was also hanging from the IV pole. There was no date or time present on the bag of Cipro or IV tubing.

Review of the medical record revealed that patient #9 was admitted to the hospital after outpatient surgery. The medical record noted that a registered pharmacist reviewed medication orders and patient #9's allergies on 1/24/18 at 12:25 PM during patient registration. The pre-operative medication written was Cipro 400 milligrams (mg.) IV on call to operating room. A note dated 1/25/18 11:34 AM read, "Attn. Pharmacy Please be advised that [patient # 9] surgery end time 8:34 AM last dose of antibiotics given Cipro 400 mg. at 7:30 AM."

On 1/25/18 at 8:38 AM, the documented surgical physician orders read "review record then admit." The orders were called in at 8:36 AM. The patient was placed on the census of an attending physician. Orders included bed rest, continuous bladder irrigation, consult infectious disease (ID) physician, and Percocet 5/325 mg by mouth as needed. A stamp documented that surgery ended at 8:34 AM. The last dose of antibiotic Cipro 400 mg. was given at 7:30 AM. There was no written order for Cipro in the surgical physician's post surgery orders.

Review of the medication administration record dated 1/25/18 revealed a scheduled order for Ciprofloxacin in Dextrose 5% in Water solution 400 mg. IV every 12 hours to start at 2 PM. The 7 AM to 5 PM nurse gave the first dose at 3:27 PM. At 2:52 AM on 1/26/18 a second dose was given.

Interview on 1/26/18 at 3:15 PM with the director of pharmacy services confirmed that the pharmacy entered the order for Ciprofloxacin when the patient was admitted to the hospital. At 3:45 PM, the Registered Nurse Director of the medical/surgical progressive care units confirmed there was no written, verbal, or telephone order for the medication Ciprofloxacin and there was no order to discontinue the Ciprofloxacin after it had been added as an order.

Review of the "Medication Ordering" policy/procedure MRMC.HID.67 original date 3/21/2012 last revised on 12/05/17 read, "Plan: Medication orders....C. Only medications needed to treat the patient are ordered. If not apparent, there will be a documented diagnosis, condition, or indication for each medication....3 B. Antibiotics written as 'on call to OR' will be interpreted to administer in the holding room prior to the surgery indicated...."
Further record review revealed that there was no additional order to continue the Ciprofloxacin antibiotic after the surgical procedure.

Based on observation, interview and record review, the hospital failed to have a physician's order authenticated accurately, resulting in 1 of 30 sampled patients receiving additional doses of an intravenous (IV) antibiotic without written or verbal physician order (#9).

Findings:

Patient #9 was observed on 1/26/18 at 11:53 AM sitting up in a chair eating his lunch. The patient was receiving IV normal saline 0.9% solution. An empty bag of Ciprofloxacin (Cipro) was also hanging from the IV pole. There was no date or time written on the bag of Cipro or IV tubing.

Review of the medical record revealed that the patient was admitted to the hospital after outpatient surgery. A registered pharmacist noted that orders and allergies were reviewed on 1/24/18 at 12:25 PM during patient #9's registration. The pre-operative medications documented Cipro 400 milligrams (mg.) IV on call to operating room.
A note dated 1/25/18 11:34 AM read, "Attn. Pharmacy Please be advised that the [patient # 9] surgery end time 8:34 AM last dose of antibiotics given Cipro 400 mg at 7:30 AM."

On 1/25/18 at 8:38 AM, physician orders revealed a review of record ,then admit. The physician was called at 8:36 AM. The patient was placed on the census of an attending physician. Orders included bed rest, continuous bladder irrigation, consult infectious disease (ID) physician, and Percocet 5/325 mg. by mouth as needed. There was no written order to continue Cipro after surgery.

A Progress note from the ID physician, dated 1/25/18 and electronically signed at 1:03 PM, read, "Impression /recommendations: Status post uneventful urologic procedure under the coverage of Ciprofloxacin as antimicrobial prophylaxis. I feel the patient has received sufficient antimicrobial prophylaxis and will discontinue Ciprofloxacin at this time."

Review of the medication administration record, dated 1/25/18, revealed a scheduled order for Ciprofloxacin in Dextrose 5% in Water 400 mg. IV every 12 hours to start at 2 PM, which was verified by the nurse at 1:49 PM.
The 7 AM to 5 PM nurse documented that she the gave the first dose of Cipro at 3:27 PM . An additional dose was documented as given on 1/26/18 at 2:52 AM.

On 1/26/18 at 3:37 PM, an interview was conducted with the Registered Nurse Director of the medical/surgical progressive care units. He confirmed that after he looked in the electronic and paper medical record, there was no order to discontinue the Cipro. He contacted the pharmacy for confirmation of the order.

Review of the policy/procedure MRMC.HID.66 titled Physician orders original date 10/01/1977 and last revised on 11/22/2017 noted, "A. All orders for treatment.... must be written clearly, completely, signed and dated by the practitioner responsible for them....D. Illegible and/or unclear orders: ... 2. if an order is received in Pharmacy without clarification, Pharmacy shall contact the physician....4. The nursing and Pharmacy departments equally share responsibilities for contacting the physician."

An interview on 1/26/18 at 3:15 PM with the director of pharmacy services confirmed that pharmacy entered the order for Ciprofloxacin. At 3:45 PM, the director of pharmacy services confirmed there was no written, verbal, or telephone order for the medication Ciprofloxacin and there was no order to discontinue the Cipro.