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HCA FLORIDA OCALA HOSPITAL
ADMINISTRATION OF DRUGS
Tag No.: A0405
Based on medical record review and interview the facility failed to ensure that physician ordered medications were administered to 1 of 3 (#1) patients as ordered.
Findings:
During medical record review for Patient #1 it was revealed that the patient was admitted to the emergency room on 12/14/10. The physician ordered 30 grams (g) Kayexalate, 1 amp of calcium chloride, 1 amp of bicarbonate, 10 units of regular insulin and 1 amp of dextrose 50. All medications were given per review of the emergency room records. The patient was admitted to the facility with continuation of home medications and the laboratory results were to be re-checked the next day. On 12/15/10 at 11:07 the physician ordered "Lasix 20 [milligrams (mg)] x 1, Albuterol nebulizer (10 mg in 4 [milliliters (ml)] saline) over 10 minutes and Kayexalate 30 g PR [every] 6 hours. Review of the medication administration record (MAR), with the Quality Management team revealed that all medications were given except for the order for the "Lasix 20 mg x 1."
Interview with the Quality Management Director on 2/11/11 at 1 PM stated that the pharmacy did a search of charges/dispensed medications for Patient #1 for the 12/14/10 to 12/16/10 admission. The pharmacy search revealed that the medication was not dispensed or given.
Review of the facility's medication administration policy page 1 number 5 "all medications will be dispensed by a registered pharmacist with a written order. The policy also stated on page 2, number 8, "medications will be administered in accordance with standard hours for treatments and medication administration of medications policy unless otherwise specified by the physician."
An electronic mail (e-mail) received from the facility ' s Director of Risk Management on 2/14/11 at 3:45 PM revealed that as per the Director of Pharmacy there is no policy for ensuring the administration of patient ' s medication. According to the e-mail, " Once [pharmacy] key in the medication, it is the nursing ' s responsibility to ensure its administration. "