HospitalInspections.org

Based on clinical record review and facility document review, it was determined the facility staff failed to ensure medications were administered and/or removed according to the written order for one (1) of (9) patients sampled.

The findings were:

A review was conducted of Patient #2's medication administration record (MAR). A lidocaine-menthol (Lidopatch) 3.6-1.25% patch was ordered 11/18/2021. This is a pain patch applied to the skin daily, as needed. The instructions read as follows: "Remove and discard patch within 12 hours or as directed by MD [Medical Doctor]". The surveyor requested to review any variances in medication administration for the patch between 12/1/2021 through 12/21/2021. The report revealed there were seven (7) occurrences where the patch was removed outside of the timeframe it was scheduled and seven (7) occurrences where a new patch was applied outside of the timeframe it was scheduled.

A review of a facility document titled, Medication Administration, was reviewed and reads in part: "...V. PROCEDURE... C... 2. Medications are obtained as close to the designated administration time as possible and kept secured until administered to the patient... b. As needed medications are obtained only when needed for administration... G. Administering the Medication... 1... d. Right time: verify correct time and administer as close as possible to the scheduled time... ii. As needed medications are administered based on clinical indication using the prescribed timeframe. aa. As needed medications given earlier than the ordered frequency but within the appropriate administration window have a documented reason as well as an order in the EHR [Electronic Health Record]. Administration window follows timeliness guidelines as outlined... bb. If an as needed medication is needed outside of the prescribed frequency and appropriate administration window, the provider is contacted for a new frequency-adjusted order... H. Monitoring... 3. Document and report to provider: a. Patient refusal of medication that impacts their plan of care; or b. If a patient does not meet the criteria for administration of the medication... Appendix A: Medication Administration Timeliness Guidelines... Non-Time Critical Scheduled Medications... Medication Order - Medication orders scheduled more frequently than daily but no more frequently than every 4 hours (e.g. every 4 hours, every 6 hours, every 8 hours, etc)... Within 1 hour before or after scheduled time... Daily, weekly, monthly medications... Within 2 hours before or after scheduled time...".