HospitalInspections.org

Based on document review and staff interviews, the acute care hospital staff failed to ensure the nursing staff documented the reason they administered patients as needed medications for 12 of 12 closed records (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, and Patient #12) and 4 of 4 open records (Patient #13, Patient #14, Patient #15, and Patient #16) where the patient received as needed medications other than pain medication. Failure to document the reason the nursing staff administered the medications could potentially result in the hospital staff administering the medication without justifying the clinical need for the medication, and potentially allowing the nursing staff to administer the medications for reasons other than the reason written in the order. The hospital's administrative staff identified an average of 153 inpatients per day.


Findings include:

1. Review of Patient #1's medical record revealed the hospital staff admitted Patient #1 to the hospital on 5/29/18. The nursing staff administered Klonopin (a medication to calm anxiety) to Patient #2. The nursing staff failed to document the reason why they administered the Klonopin to Patient #1 on 3 of 4 times the nursing staff administered the Klonopin.

2. Review of Patient #2's medical record revealed the hospital staff admitted Patient #2 to the hospital on 4/26/18. The nursing staff administered Ativan (a medication to calm anxiety) to Patient #2. The nursing staff failed to document the reason why they administered the Ativan to Patient #2 on 1 of 3 times the nursing staff administered the Ativan. The nursing staff administered Zofran (a medication to control nausea) to Patient #2. The nursing staff failed to document the reason they administered the Zofran to Patient #2 on 3 of 5 times the nursing staff administered the Zofran.

3. Review of Patient #3's medical record revealed the hospital staff admitted Patient #3 to the hospital on 4/16/18. The nursing staff administered Zofran to Patient #2. The nursing staff failed to document the reason why they administered the Zofran to Patient #3 on 2 of 2 times they administered the Zofran to Patient #3.

4. Review of Patient #4's medical record revealed the hospital staff admitted Patient #4 to the hospital on 5/30/18. The nursing staff administered Maalox (a medication to control heartburn) to Patient #4. The nursing staff failed to document the reason why they administered the Maalox to Patient #4 on 1 of 1 time they administered Maalox to Patient #4. The nursing staff administered Zofran to Patient #4. The nursing staff failed to document the reason they administered the Zofran to Patient #4 on 6 of 6 times they administered Zofran to Patient #4.

5. Review of Patient #5's medial record revealed the hospital staff admitted Patient #5 to the hospital on 1/26/18. The nursing staff administered Cepacol (a throat lozenge to help with a sore throat) to Patient #5. The nursing staff failed to document the reason they administered the Cepacol to Patient #5 on 2 of 2 times they administered Cepacol to Patient #5. The nursing staff administered Cetaphil (a topical cream for dry skin) to Patient #5. The nursing staff failed to document the reason they administered the Cetaphil to Patient #5 on 1 of 1 time they administered Cetaphil to Patient #5.

6. Review of Patient #6's medical record revealed the hospital staff admitted Patient #6 to the hospital on 2/13/18. The nursing staff administered Reglan (a medication to control nausea) to Patient #6. The nursing staff failed to document the reason they administered the Reglan to Patient #6 on 1 of 1 time they administered Reglan to Patient #6. The nursing staff administered Zofran to Patient #6. The nursing staff failed to document the reason they administered the Zofran to Patient #6 on 5 of 7 times they administered Zofran to Patient #6.

7. Review of Patient #7's medical record revealed the hospital staff admitted Patient #7 to the hospital on 4/4/18. The nursing staff administered Nicotrol (a medication to help smokers control their cravings). The nursing staff failed to document the reason they administered the Nicotrol to Patient #7 on 23 of 23 times they administered the Nicotrol to Patient #7. The nursing staff administered Colace (a stool softener to relieve constipation) to Patient #7. The nursing staff failed to document the reason they administered the Colace to Patient #7 on 1 of 1 time they administered Colace to Patient #7.

8. Review of Patient #8's medical record revealed the hospital staff admitted Patient #8 to the hospital on 2/28/18. The nursing staff administered a menthol throat lozenge to Patient #8. The nursing staff failed to document the reason why they administered a menthol throat lozenge to Patient #8 on 1 of 1 time they administered menthol throat lozenges to Patient #8. The hospital staff later admitted Patient #8 back to the hospital on 9/28/18. The nursing staff administered BenGay (a cream to relieve discomfort) to Patient #8. The nursing staff failed to document the reason they administered the BenGay to Patient #8 on 1 of 1 time they administered BenGay to Patient #8.

9. Review of Patient #9's medical record revealed the hospital staff admitted Patient #9 to the hospital on 5/23/18. The nursing staff administered Flexeril (a powerful muscle relaxing medication) to Patient #9. The nursing staff failed to document the reason they administered the Flexeril to Patient #9 on 1 of 1 time they administered Flexeril to Patient #9.

10. Review of Patient #10's medical record revealed the hospital staff admitted Patient #10 to the hospital on 3/31/18. The nursing staff administered Librium (a medication to control the symptoms of alcohol withdrawal) to Patient #10 . The nursing staff failed to document the reason why they administered Librium to Patient #10 for 1 of 1 time they administered Librium to Patient #10.

11. Review of Patient #11's medical record revealed the hospital staff admitted Patient #11 to the hospital on 3/16/18. The nursing staff administered Robitussin-DM (a cough syrup) to Patient #11. The nursing staff failed to document the reason they administered Robitussin-DM to Patient #11 on 2 of 3 times they administered Robitussin-DM to Patient #11.

12. Review of Patient #12's medical record revealed the hospital staff admitted Patient #12 to the hospital on 1/17/18. The nursing staff administered Ativan to Patient #12. The nursing staff failed to document the reason they administered Ativan to Patient #12 on 2 of 2 times they administered Ativan to Patient #12. The nursing staff administered Haldol (a powerful anti-psychotic medication) to Patient #12. The nursing staff failed to document the reason they administered Haldol to Patient #12 on 3 of 3 times they administered Haldol to Patient #12.

13. Review of Patient #13's medical record revealed the hospital staff admitted Patient #13 to the hospital on 10/14/18. The nursing staff administered milk of magnesia (a medication to relieve constipation) to Patient #13. The nursing staff failed to document the reason they administered the milk of magnesia to Patient #1 on 1 of 1 time they administered milk of magnesia to Patient #13.

14. Review of Patient #14's medical record revealed the hospital staff admitted Patient #14 to the hospital on 10/9/18. The nursing staff administered Vistaril (a medication to control anxiety) to Patient #14. The nursing staff failed to document the reason they administered the Vistaril to Patient #14 on 2 of 2 times they administered the Vistaril to Patient #14.

15. Review of Patient #15's medical record revealed the hospital staff admitted Patient #15 to the hospital on 10/7/18. The nursing staff administered albuterol (a medication to open the airways in a patient's lungs) to Patient #15. The nursing staff failed to document the reason they administered the albuterol to Patient #15 on 1 of 1 time they administered albuterol to Patient #15. The nursing staff administered Reglan to Patient #15. The nursing staff failed to document the reason they administered the Reglan to Patient #15 on 1 of 1 time they administered the Reglan to Patient #15. The nursing staff administered Ativan to Patient #15. The nursing staff failed to document the reason they administered the Ativan to Patient #15 on 2 of 2 times they administered Ativan to Patient #15.

16. Review of Patient #16's medical record revealed the hospital staff admitted Patient #16 to the hospital on 10/15/18. The nursing staff administered Cepacol to Patient #16 on 10/16/18 at 8:57 PM. The nursing staff failed to document the reason they administered Cepacol to Patient #16 on 1 of 1 time they administered Cepacol to Patient #16. The nursing staff administered Lopressor (a medication to lower the heart rate and blood pressure) to Patient #16. The nursing staff failed to document the reason they administered Lopressor to Patient #16 on 2 of 5 times they administered Lopressor to Patient #16.

17. Review of the policy "Medication Administration," reviewed 5/16/18, revealed the policy lacked a requirement for the nursing staff to document the reason they administered a medication, other than pain medications, on an as needed basis to patients.

18. During an interview on 10/23/18 at 09:00 AM, the Director of Accreditation and Licensure acknowledged the findings.