HospitalInspections.org

Based on record review, staff interview and policy review, it was determined that the facility failed to ensure medications are administered according to physician orders and facility policy for 1 (#1) of 3 sampled patients. The practice does not ensure safe and effective administration of medications to patients.

Findings include:

1. Review of the medical record for patient #1 revealed physician orders on 11/24/10 at 7:00 a.m. for an order of Prednisone 20 mg (milligrams) in a.m. and 10 mg in p.m., begin this a.m. Review of the patient ' s MAR (Medication Administration Record) revealed the Prednisone 20 mg in a.m. was given on 11/24/10 at 4:00 p.m. Review of the nursing documentation revealed no indication why the Prednisone was not given in the a.m. Review of the MAR revealed the Prednisone 10 mg in p.m was not given. Review of the nursing documentation revealed no indication why the Prednisone 10 mg was no given. Interview with the manager of clinical standards on 1/04/10 at 6:05 p.m. confirmed the Prednisone was not given as ordered by the physician.

2. Review of the facility ' s policy, " Peripheral Short IV Care Protocol from Insertion to Discontinuation " , was reviewed. The policy stated a peripheral IV will be flushed every 8 hours with 2 ml (milliliters) of NS (Normal Saline) before and after any medication given through the peripheral IV. The medical record for patient #1 was reviewed. Review of the physician orders revealed an order for Zithromax 500 mg IV daily and Solu-medrol 60 mg IV every 12 hours. Review of the patient ' s MAR revealed on 11/24/10 the patient was given Solu-medrol 60 mg IV at 10:00 p.m. There was no documentation that nursing flushed the peripheral IV with 2 ml of NS before and after the medication was given. Review of the MAR revealed on 11/24/10 at 11:00 pm Zithromax 500 mg IV was given. There was no documentation that nursing flushed the peripheral IV with 2 ml of NS before and after the medication was given. There was no documentation the patient ' s peripheral IV was flushed with 2 ml of NS every 8 hours. Interview with the manager of clinical standards on 1/04/10 at 6:05 p.m. confirmed no documentation the peripheral IV flushes were completed as required by the facility's policy.