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CLEVELAND CLINIC
ADMINISTRATION OF DRUGS
Tag No.: A0405
Based on medical record review, policy and report review and interview, the facility failed to ensure medications administered to one patient (Patient #1) of ten medical records reviewed were documented in the medical record. This had the potential to affect all of the facility's 1144 active patients.
Findings include:
The facility's Medication Administration Protocol was reviewed. The policy stated to document at the time of medication administration.
Review of a report listing medications dispensed from the facility's Pyxis system for Patient #1 revealed Staff B, Registered Nurse, removed 2 mg of Morphine on 03/09/18 at 2:44 PM and 2 mg of Morphine at 6:24 PM.
On 03/15/18 at 1:47 PM, Staff B was interviewed. Staff B reported she administered two doses of Morphine to Patient #1 on 03/09/18 and omitted documenting the first dose she administered.
On 03/15/18 at 12:47 PM, Staff F, Director of Medication Safety Services, was interviewed. Staff F confirmed the electronic medical record lacked documentation of the administration of the 2:44 PM dose of Morphine.