HospitalInspections.org

Based on record review, policy review and interviews it was determined the pharmacy failed to ensure medications orders were accurate and medications were administered as ordered for 1 (#5) of 11 sampled records reviewed.

Findings include:

Patient #5 was admitted on 12/04/2014. A review of the physician's orders dated 12/04/2014 at 6:39 p.m. revealed:
? Subutex 4 milligrams sublingual at 9:00 a.m. and 5:00 p.m. (May repeat times 1 dose in 1-4 hours if ineffective in relieving signs/symptoms) times 2 days (Opioid Detox Day 1 & Day 2)-Do Not give if sedated or blood pressure less than 90/60 or heart rate less than 60.
? Subutex 2 milligrams sublingual at 9:00 a.m. and 5:00 p.m. (May repeat times 1 dose in 1-4 hours if ineffective in relieving signs/symptoms) times 2 days (Opioid Detox Day 3 & Day 4)-Do Not give if sedated or blood pressure less than 90/60 or heart rate less than 60.
? Subutex 2 milligrams sublingual at 9:00 a.m. (Opioid Detox Day 5)-Do Not give if sedated or blood pressure less than 90/60 or heart rate less than 60.

A review of patient #5's Medication Administration Record (MAR) revealed the medication was profiled and administered on the following dates and times:
On 12/05/14 Subutex 4 milligram was given sublingual at 8:23 a.m. and 5:18 p.m.
On 12/06/14 Subutex 2 milligram was given sublingual at 8:37 a.m. at 4:29 p.m. and 5:44 p.m.
On 12/07/14 Subutex 2 milligram was given sublingual at 8:40 a.m. at 10:20 a.m. at 4:28 p.m. and 6:19 p.m.

An interview with the Director of Nursing confirmed the medication was profiled and administered incorrectly on 12/06/14 and 12/07/14.