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Tag No.: A0395
Based on document review and interview, it was determined that for 2 of 5 (Pt #3 and 4) clinical records reviewed on the telemetry unit, the Hospital failed to ensure PRN (as needed) medications were evaluated for effectiveness following the administration.
Findings include:
1. Hospital policy entitled, "Medications, Safe Administration," (effective date: 06/13/2013) required, "II. Medication Administration Recording 6. Administering a PRN med requires a PRN reason. E. eMAR Downtime Procedure: iv...Note the patient's response to PRN medications."
2. The clinical record of Pt #3 was reviewed on 7/8/14 at approximately 10:30 AM. Pt #3 was a 66 year old male admitted on 7/5/14 with a diagnosis of Rabdomylosis. Pt #3's clinical record contained a physician's order dated 7/7/14 that required "Hydrocodone/APAP 5/325 (Norco) 1 tab every 6 hours as needed." Nursing documentation dated 7/7/14 at 6:43 AM included that Pt #3 received 1 tablet as required. Pt #3's clinical record lacked documentation of a follow up to the administration of the PRN medication.
3. The clinical record of Pt #4 was reviewed on 7/8/14 at approximately 10:30 AM. Pt #4 was a 71 year old male admitted on 7/7/14 with a diagnosis of Right Leg Gangrene status post right below the knee amputation. Pt #4's clinical record contained a physician's order dated 7/7/14 that required "Acetaminophen ES 500 mg (Tylenol Extra Strength) 500 mg every 6 hours as needed." Nursing documentation dated 7/7/14 at 4:49 PM and 7/8/14 at 6:32 AM included that Pt #4 received 1 tablet as required. Pt #4's clinical record lacked documentation of a follow up to the administration of the two (2) PRN medications.
4. The Vice President of Patient Care stated during an interview on 7/8/14 at approximately 1:15 PM that the PRN medications should have been evaluated for effectiveness.