HospitalInspections.org

Based on review of Hospital documents and staff interview, it was determined that in 1 of 10 (Pt #1) clinical records reviewed, the Hospital failed to ensure pain medications were administered as ordered.

Findings include:

1. Hospital policy entitled, "Medication Administration - Accuracy," (effective 1/97) required,"Procedure for Administration... Check...time against medication profile".

2. The clinical record of Pt #1 was reviewed on 11/20/12. Pt #1 was a 63 year old female that presented to the Hospital's Emergency Department (ED) on 10/26/10 via ambulance for complaint of a fall at 4:00 AM. The patient was discharged home, and readmitted at 9:30 AM on 10/26/10, with a diagnosis of, "possible acute fracture of symphysis pubis and right inferior pubic ramus." A physician's order dated 10/26/10 at 6:13 AM required that Pt #1 receive Dilaudid 0.5 mg IVP (intravenous push) every 2 hours as needed for pain. Nursing documentation included that Pt #1 received IVP Dilaudid 0.5 mg on 10/26/10 at 11:50 PM and on 10/27/10 at 1:00 AM (1 hour 10 minutes later), on 10/27/10 at 3:45 AM and 5:30 AM (1 hr 45 minutes later), and again at 7:10 AM (1 hour 45 minutes later).

3. The Unit Manager of the Medical/Surgical Unit stated during an interview on 11/20/12 at 1:00 PM, that the medication was not given at the appropriate time.