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Based on record review, staff interview and clinical record and policy review, it was determined that the facility failed to ensure medications were administered according to physician orders for one (#2) of five records reviewed. This practice does not ensure safe and effective administration of medications.

Findings include:

Patient #2 was admitted on 2/1/10. A verbal order taken by a Registered Nurse was written as catapres #3 topical and nitropaste 1 inch topical. The order did not include frequency.

The facility's policy "Medications: Ordering, Processing, Dispensing and Administration" requires the complete order contains frequency.

Review of the Medication Administration Record revealed that the two medications were not administered. There was no evidence in the clinical record that the order had been clarified or cancelled.

The Director of Nursing Systems confirmed the above findings during interview on 2/11/10 at approximately 2:00 p.m.

Based on record review and staff interview, it was determined that the facility failed to ensure patient allergy was considered in the distribution of medication to 1 (#1) of 4 sampled patients. This practice does not provide for safe patient care and may cause an increased stay.

Findings include:

Patient #1's nursing and medical staff documentation noted that the patient has an allergy to Cipro and Flagyl. The medication allergy had been identified by the Emergency Department physician during a previous visit on 12/29/09. On 1/6/10 a consulting physician wrote an order for Flagyl 500 milligrams orally every 6 hours. Review of the Medication Administration Record (MAR) revealed that the order was transcribed onto the form. The Flagyl was listed as a medication allergy on the MAR. The MAR noted that the medication was administered a total of 3 times from 6:00 p.m. on 1/6/10 until the following morning.
The nursing staff failed to note the allergy listed on the MAR and administered the medication inappropriately.

The Director of Pharmacy was interviewed on 2/11/10 at approximately 3:00 p.m. He reported that facility's medication profile system is computerized. The allergy had been appropriately entered into the profile for patient #1. The pharmacist reviewing the medication order failed to recognized an alert that the patient was allergic to the medication ordered and entered the medication into the MAR.