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333 HARRISBURG AVENUE

LANCASTER, PA 17603

ADMINISTRATION OF DRUGS

Tag No.: A0405

Based on review of facility documentation, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure drugs were administered in accordance with the order of a physician for one of one medical records reviewed (MR).

Findings included:

A review of facility policy "Medication Administration- Guidelines ;last revised 5/2018" revealed ...Procedure: ...B. Physician/APRN orders must be checked against Medication Administration Record before preparing a new, stat, or one-time order...L. The five (5) rights of medication administration will be followed: 1. the right amount. 2. the right medicine..."

An interview on March 16, 2019, with EMP2 revealed the patient was ordered Haldol but the patient received Haldol Decanoate. In other words, the patient was ordered short acting Haldol but received Haldol Decanoate, a long acting Haldol

EMP3 stated it was found in the AM when the clinician was reviewing the overrides and brought it to her attention. An override occurs when a medication is ordered, and the Pharmacy is not inhouse to profile it on the patients record. Two nurses are to review the order and the medication that is pulled from the omni cell. Alerted was wrong med when first entered in omni cell, Haldol did state that it was a monthly dose, and when scanned alerted wrong med. There was Pharmacist on call if they had questions.

CONTENT OF RECORD: COMPLICATIONS

Tag No.: A0465

Based on review of facility documentation, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure that documentation of the patient receiving incorrect medication was documented on the patient's medical record (MR).

Findings include:

A review of facility policy "Legal Medical Record/Documentation Standards, last revised 03/2019" revealed " ...Documentation Content:...When an incident/event occurs, document the facts of the occurrence. Do not document or refer to the existence of an Event Report. Service documentation should include:...N. Medical treatment notes and reports...P. Evidence of medication and dosage administered...R. Physician, or qualified NP or PA, and nurse progress notes..."

The review of the medical record did not reveal any documentation of the patient receiving the incorrect type of Haldol (the patient was ordered short acting Haldol but received Haldol Decanoate, a long acting Haldol).
An interview on March 18, 2019, at 2:00 PM with EMP2 revealed the medical record did not contain documentation of the patient receiving the incorrect type of Haldol or being told of the error.