HospitalInspections.org

Based on record review, policy review and staff interview it was determined that the nursing staff failed to administer medications as ordered by the physician for 2 (#1,#7) of 8 sampled patients. This practice did not ensure effective medication therapy was maintained.


Findings include:

1. Review of patient #1's physician order dated 1/17/11 indicated Dilaudid 1-2 milligrams (mg) every 6 hours. On 1/25/11 he changed the order to 1-2 mg every 4 hours as needed for pain. The nurse documented that the patient reported pain on 1/28/11 at 6:20 p.m. as 5 on a 0-10 scale with 10 being the worst pain. There was no documentation of pain medication being administered at that time. The patient was assessed again at 8:30 p.m. The patient reported pain as 10 on the pain scale. Review of the Medication Administration Record (MAR) revealed that the pain medication was not administered until 9:26 p.m., which was almost 1 hour later. There was no documentation as to why the pain was not addressed at 6:20 p.m. and no documentation regarding the delay in administering the medication after the assessment at 8:30 p.m.

The Assistant Chief Nursing Officer (CNO) confirmed the above findings on 4/8/11 at approximately 4:30 p.m.

2. Review of the nursing documentation for patient #1 revealed the nursing staff failed to reassess the patient's pain level following administration of pain medication at the following times:
1/25/11 at 2:39 p.m.
1/27/11 at 11:54 p.m.
1/29/11 at 11:46 p.m.
1/30/11 at 1:45 p.m.
1/31/11 at 2:43 p.m.

The Assistant CNO confirmed the above findings on 4/8/11 at approximately 4:30 p.m.

3. Review of patient #7's clinical record revealed a physician order on 4/05/11 for Tylenol 650 mg by mouth every 4 hours as needed for pain. Review of the MAR revealed Tylenol 650 mg was administered on 4/05/11 at 7:41 p.m. for a headache. Documentation revealed the patient rated the pain as 9 on a scale of 1-10 with 10 being the worst pain. Review of the nursing documentation revealed the patient's pain was reassessed at 11:59 p.m. approximately four hours after administration of the Tylenol.
Review of the MAR revealed on 4/06/11 at 1:39 a.m. Tylenol 650 mg was administered by mouth for a headache. Documentation revealed the patient rated the pain as a 5. Review of the nursing documentation revealed no reassessment of the patient's response to the pain medication. Review of the MAR revealed on 4/06/11 at 10:06 p.m., Tylenol 650 mg was administered by mouth for a headache. Documentation revealed the patient rated the pain as a 5. Review of the nursing documentation revealed no reassessment of the patient's response to the pain medication.

The facility's policy "Pain Management" 2.600.154, last revised 10/11 required that the patient be assessed within 1 hour of pain medication administration to assessed effectiveness of the medication.

4. Review of the medical record for patient #1 revealed the physician ordered Geodon 10 mg intramuscularly every 6 hours as needed for agitation and ativan 0.5 mg intravenously every 6 hours as needed for agitation. Review of the MAR revealed that ativan 0.5 mg was administered on 1/18, 1/25, 1/26, 1/27, and 1/30/11. There was no documentation of the patient's behavior that would require the administration of the medication. Geodon was administered on 1/19, 1/20, 1/21, and 1/22/11. On 1/22/11 the medication was administered at 10:29 p.m. The nursing staff documented the patient as being cooperative at that time. Again there was no documentation of the behavior that would require the administration of the medication on those days.
The assistant CNO was interviewed on 4/8/11 at approximately 4:30 p.m. and confirmed that lack of documentation supporting the appropriateness of the medication.

Based on clinical record review, staff interview and review of policy and procedures it was determined the facility failed to ensure blood transfusions were administered according to the facility's policy and procedures for one (#7) of eight records reviewed.

Findings include:

Review of the clinical record for patient #7 revealed a physician order dated 4/06/11 to type and cross match and transfuse three units of PRBC (Packed Red Blood Cells). Review of the record revealed the first unit was initiated on 4/06/11 at 5:33 p.m. Documentation revealed two subsequent units were transfused at 9:14 p.m. and on 4/07/11 at 1:35 a.m. Review of the clinical record revealed no evidence of informed consent for administration of blood.
An interview with the director of the unit on 4/08/11 at 11:40 a.m., confirmed there was no consent present in the clinical record.

Review of the facility's policy, "Blood/Blood Component Administration" , last revised 4/2010, stated informed consent was required for all Blood and/or Blood Component administration.