HospitalInspections.org

Based on clinical record review and interview, it was determined nursing staff failed to administer three doses of medication to Patient #1 as ordered by the physician. Failure to administer the medication per physician's orders did not ensure Patient #1's infection was adequately treated and resolved. The failed practice affected Patient #1 from 06/15/14 through 06/17/14. Findings follow:

A. Review of Patient #1's clinical record revealed nasal Bactroban 2% ordered by Trauma Surgeon at 0833 on 06/13/14. The medication was ordered to nares 2 times daily in response to a positive MRSA (methicillin resistant staph aureus) culture result.

B. Review of the Medication Administration Record for Patient #1 revealed documentation on 06/15/14 at 2200 by Registered Nurse (RN) #1 the medication was not given because it was not available, on 06/16/14 at 2111 by RN #2 the medication was not given because it was not available and on 06/17/14 at 1000 by RN #3 the medication was not given because it was not available.

C. The Director of Surgical Services was asked at 1500 why the medication was not available for those three doses. At 1510 the Director of Surgical Services returned to the conference room and stated there was no national shortage of Bactroban and there was never a time period where the facility was without Bactroban.