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HCA FLORIDA LAKE MONROE HOSPITAL
No Description Available
Tag No.: A0404
Based on interview and record review, the facility failed to ensure that nursing staff followed the physician's order for the administration of Dilaudid for 1 of 9 sampled patients (#9).
Findings:
A review of the medical record of patient #1 indicted the patient was admitted on 2/11/11.
Physician orders of 2/16/11 at 7 AM read, "Change Dilaudid to every 2 hours 0.5 mg. (milligrams) IV (intravenous)". The physician did not specify in this order for it to be given PRN (as needed), therefore, the medication was prescribed specifically to be given every two hours. The medical record indicated that Dilaudid was administered at the prescribed dose 7:43 AM on 2/16/11.
Nurse's notes at 7:59 AM read, "Pt in bed sleeping quietly." Nurse's notes at 8:37 AM read, "Dr. ... in to see patient."
Per the new physician orders of 7 AM (see above), the patient would have been due for another dose of non-PRN Dilaudid at approximately 9:43 AM. There was no evidence that it was administered at this time, or shortly thereafter, irrespective of the patient's pain status at the time.
Physician orders of 2/16/11 at 11 AM read, "Start Dilaudid PCA 0.2 mg/hr (1 ml/hr) continuous infusion." Nurse's notes indicated that the Dilaudid PCA pump was initiated at 11:27 AM. This was the first administration of Dilaudid in any form since the 7:43 AM administration.
During an interview of the Quality Manager during a follow-up call on 4/19/11 at approximately 10 AM, she confirmed the findings.
ADMINISTRATION OF DRUGS
Tag No.: A0405
Based on interview and record review, the facility failed to ensure that nursing staff followed the physician's order for the administration of Dilaudid for 1 of 9 sampled patients (#9).
Findings:
A review of the medical record of patient #1 indicted the patient was admitted on 2/11/11.
Physician orders of 2/16/11 at 7 AM read, "Change Dilaudid to every 2 hours 0.5 mg. (milligrams) IV (intravenous)". The physician did not specify in this order for it to be given PRN (as needed), therefore, the medication was prescribed specifically to be given every two hours. The medical record indicated that Dilaudid was administered at the prescribed dose 7:43 AM on 2/16/11.
Nurse's notes at 7:59 AM read, "Pt in bed sleeping quietly." Nurse's notes at 8:37 AM read, "Dr. ... in to see patient."
Per the new physician orders of 7 AM (see above), the patient would have been due for another dose of non-PRN Dilaudid at approximately 9:43 AM. There was no evidence that it was administered at this time, or shortly thereafter, irrespective of the patient's pain status at the time.
Physician orders of 2/16/11 at 11 AM read, "Start Dilaudid PCA 0.2 mg/hr (1 ml/hr) continuous infusion." Nurse's notes indicated that the Dilaudid PCA pump was initiated at 11:27 AM. This was the first administration of Dilaudid in any form since the 7:43 AM administration.
During an interview of the Quality Manager during a follow-up call on 4/19/11 at approximately 10 AM, she confirmed the findings.