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Based on document review and interview, the facility failed to administer medications as ordered by a practitioner in 1 of 5 MR's reviewed.

Findings:

1. Policy/procedure, Policy No. OP.06.16, Home Pain Medication Use on the Inpatient Unit, revised/reviewed 7/16, indicated:
A. if the patient is unable to provide the medications the dispensing pharmacy is to be contacted.
B. if no refills are allowed, the prescribing physician will be contacted to authorize a refill or give an order to the RN for meds to be used during the inpatient stay only

2. Policy/procedure, SOC 5.2.0, Physician Orders, transcribing, revised/reviewed 7/16, indicated the professional nurse is accountable and responsible for documenting and administration of all physician orders.

3. Admission Orders indicated on 7/19/16 per medical staff 1 (Nurse Practitioner [NP]): morphine 30 mg BID orally - pain and Percocet 10 mg orally TID - pain. To use morphine and Percocet from home meds.

4. Medication Administration Record (MAR) lacked documentation of administration of morphine 30 mg BID orally on 7/19/16 at 0800 and 2000 hours and lacked documentation of administration of Percocet 10 mg TID orally on 7/19/16 at 0800, 1400 and 2000 hours.

5. On 9/15/16 at approximately 1315 hours, staff 2 (Executive Director of Medical Services) was interviewed and confirmed patient 1's home supply of morphine and Percocet were not provided to the facility. Staff 2 confirmed patient 1 did not receive doses of morphine and Percocet during facility admission as ordered per physician. Staff 2 confirmed patient 1's MR lacked documentation of notification of attending physician regarding patient 1's missed medication doses of morphine and Percocet. Staff 2 confirmed patient1's MR lacked documentation of notification to dispensing pharmacy and prescribing physician of patient 1's inability to provide facility with home pain medications morphine and Percocet.

Based on document review and interview, the facility failed to provide a medical record that contained information to support and describe a patient's progress and response to medications and services in 1 of 5 MR's reviewed.

Findings:

1. Policy/procedure, SOC 7.2.0, Transfer of patient to another facility, revised/reviewed 7/16, indicated: the nurse will: Complete transfer form. Call report to the transferring facility, if appropriate.

2. Policy/procedure SOC 8.0.0, Psychiatric/Medical Emergencies, revised/reviewed 7/16, indicated: Emergency Medical Care: The Hamilton Center, Inc (HCI) nurse will phone the F2 Emergency Department personnel with a report, prior to taking the patient.

3. MR lacked documentation of a transfer form and of a report given to the F2 emergency department personnel of patient status upon transfer.

3. On 9/15/16 at approximately 1315 hours, staff 2 (Executive Director of Medical Services) was interviewed and confirmed patient 1's MR lacked documentation of report given to F2 Emergency Department personnel of patient status upon transfer. Staff 2 confirmed patient 1's MR lacked documentation of completed transfer form.