HospitalInspections.org

Based on review of medical records and staff interview, the facility failed to administer a PRN (as occasion requires) medication as prescribed by a practitioner in one (#1) of 15 medical records. This failure created the potential for negative patient outcome.

The findings were:

The medical record of patient sample #1 was reviewed on 5/10/11 and 5/11/11. The patient was admitted to the facility on 2/28/11 and discharged on 4/20/11 with diagnoses of infection of gastrostomy, cerebral palsy, seizure disorder on triple antiseizure medications, mental retardation and dysphagia. On admission, the patient had been prescribed Lorazepam (Ativan) 2 mg/ml injection as needed for seizures.

According to the Medication Administration Record (MAR), dated 3/3/11 through 3/4/11, the patient was administered the prescribed amount of Ativan on 3/3/11 at 11:00 a.m. The following was documented in the nursing progress notes on 3/3/11: "DHT (Dobbhoff tube) replaced, pt. received 1 ml Ativan." There was no documentation regarding the patient having any seizure activity.

According to the MAR, dated 3/17/11 through 3/18/11, the patient was administered Ativan 1 ml on 3/17/11 at 10:30 a.m. The following was documented in the nursing progress notes on 3/17/11: "Gave Ativan 1 mg due to request of mother and agitation." There was no documentation regarding the patient having any seizure activity.

According to the MAR, dated 3/23/11 through 3/24/11, the patient was administered Ativan 1 ml on 3/23/11 at 11:30 p.m. The following was documented in the nursing progress notes on 3/23/11: "Gave Ativan 1 mg IVP (intravenous push) for anxiety." There was no documentation regarding the patient having any seizure activity.

The following was documented in the nursing progress notes on 3/14/11 at 7:00 p.m.: "Pt. observed displaying seizure activity for approx. 40 sec. bilat arm shaking vigorously, eyes rolled back in head, mouth sucking. Pt. post ictal..." On 4/14/11, the following was documented in the nursing progress notes at 2:00 p.m.: "Pts. mother stated that (pt's name) has been having seizure episodes during this shift. I was present for one of the episodes - it lasted 20 seconds. Pt. is still slightly combative but allowed tube feedings."

An interview was conducted with the Director of Nursing (DON) on 5/11/11 at approximately 11:15 a.m. The DON stated that s/he was aware of Ativan being given for anxiety on 3/23/11 by an agency nurse and s/he requested that the agency not send the nurse to the facility again. However, the DON was not aware that Ativan had been administered on two other occasions for symptoms other than the prescribed "as needed for seizures."

In summary, the patient was administered the medication Ativan for symptoms other than what was prescribed by the practitioner. Furthermore, when the patient displayed seizure activity, the medication was not given, nor was there any documentation regarding the decision not to administer the PRN medication.