HospitalInspections.org

Based on review of facility policy, medical record review, and interview, the facility failed to ensure a physician's order was obtained for the administration of a medication for 1 patient (#1) of 5 patients reviewed.

The findings included:

Review of facility policy "Electronic Medication Administration" last reviewed 9/2016, revealed "...all orders are to be scanned to pharmacy and then stamped 'scanned' on the order sheet...each medication is to be accurately transcribed to the EMR [electronic medical record] by the pharmacist...each order is to be verified for accuracy...acknowledgment signifies the user's signature and represents that the pharmacist's transcription of the medication order is correct when compared to the original provider's order..."

Medical record review revealed Patient #1 was admitted to the facility on 2/26/18 with diagnoses including Septic Shock, Sacral Decubitus Ulcer, Acute Renal Failure, Acute Respiratory Failure, and Acute Encephalopathy.

Medical record review of a Physician's Order dated 2/27/18 at 11:40 AM revealed "...Dilaudid [pain medication] 0.2-0.4 mg [milligrams] IV [intravenous] q [every] 4 hours PRN [as needed] for pain..."

Medical record review of the Nursing Flow Sheet dated 3/1/18 at 12:15 PM revealed Dilaudid 1 mg IV was administered to the patient.

Medical record review of a Nursing Flow Sheet dated 3/2/18 at 10:57 AM revealed Dilaudid 1 mg IV was administered to the patient.

Medical record review of a Nursing Flow Sheet dated 3/3/18 at 4:04 PM revealed Dilaudid 1 mg IV was administered to the patient.

Interview with the Intensive Care Unit (ICU) Nurse Manager on 3/5/18 at 2:15 PM, in the conference room, revealed the physician's order for Patient #1 was for Dilaudid 0.2-0.4 mg IV and "...there was no physician's order for the 1 mg of Dilaudid..."