HospitalInspections.org

Based on document review and staff interview, it was determined for 1 of 10 patient (Pt #1), the Hospital failed to ensure all concerns related to medication allergies were clarified with the prescribing physician before dispensing medication. This has the potential to affect all patients receiving care at the Hospital.

Findings include:

1. On 12/21/15 at 10:00 AM, the medical record of Pt #1 was reviewed. Pt #1 was admitted to the Hospital on 10/18/15 due to cellulitis of the jejunostomy tube site. Documentation on the transfer sheet indicated the patient was allergic to penicillin. Documentation on the "Medication" sheet (order #288141584) "order history" indicated the physician ordered ampicillin intraveously, 1 Gram, every 6 hours @ 200 milliliter/hour over 30 minutes (penicillin antibiotic used to treat infections). There is no documentation to indicate the pharmacist notified the prescribing physician of the patient's allergy/medication incompatibility as per Hospital policy.

2. The Hospital policy " Pharmacy ", revised 11/2014, was reviewed on 12/21/15 at 11:00 AM. Under "3." it reads "If the patient has an allergy to cephalosporins, penicillins or carbapenems the pharmacist will do the following: ....... the prescriber will be called."

3. On 12/21/15 at 3:00 PM, an interview with the pharmacist (E #6) was conducted. E #6 verbalized "I processed the order of ampicillin for the patient and I was aware of the patient's allergy to penicillin. I reviewed the medical record and didn't see any documentation of me notifying the doctor of the patient's allergy and medication incompatibility and there should have been."