HospitalInspections.org

Based on record review and interview, it was determined that the facility failed to provide medications in accordance with physician orders for one (#2) of 10 sampled records. This practice does not provide for safe and effective medication management.

Findings include:

1. Patient #2's physician orders dated 3/15/10 for Peripherally Inserted Central Catheter (PICC) instructed to flush and lock with 10 ml (milliliter) normal saline ( NS) at least every 24 hour and/or with each use.
Review of the Medication Administration Records (MAR) and nursing notes revealed no documentation of NS flush after medication administration on 03/13/10 at 7:37 p.m. and on 03/14/10 at 8:00 p.m. and 10:00 p.m. There was no documentation on 03/15/10 at 4:00 a.m., 10:00 a.m. or 12:00 p.m. There was no documentation for daily flushes on MAR or nurse ' s notes on 03/13/10, 03/14/10 and 03/15/10.
The Charge Nurse, on 3/15/10 at 3:30 p.m., confirmed the lack of documentation for the NS flush.


11553