HospitalInspections.org

Based on review of medical records, and interviews with staff, the nursing staff failed to evaluate and supervise the delivery of patient care by failing to contact a physician to clarify a medication that was questioned by a family member prior to administration for 1 of 10 sampled patients. (Pt #1)

The findings include:

Review of history and physical dated 05/22/2018 at 2128 revealed a 71 year old female "admitted to the hospital for the purpose of intravenous antibiotics....A urine culture was obtained that showed multidrug resistant Escherichia coli (bacteria found in the colon) ... She also had some worsening ....... She was recently having issues with left leg weakness and this was attributed to brain metastases (spreading of the cancer to the brain) from her small cell lung cancer ...." Review of a physician's order dated 05/27/2018 at 1348 revealed "Tramadol (Ultram--an opioid pain medication used to treat moderate to moderately severe pain) 100 mg (milligrams) every 6 hours PRN (as needed) for pain, mild (1-3), pain, moderate (4-6)." Review of a nurses note dated 05/29/2018 at 0102 revealed "At 0100 patient's son woke up as RN came into the room to administer pain medication to the patient..... RN (#1) administered tramadol to patient. Son stated he would like the (sic) speak to the supervisor regarding the patient's pain medications." Review of documentation of medication administration revealed administration of Tramadol 100 mg orally by RN #1 on 05/29/2018 at 0102. Review of the record revealed no documentation that a physician was contacted regarding the family member's request.

The assigned RN (RN #1) who administered the Ultram on 05/29/2018 at 0101 was not available for interview.

Interview on 03/20/2019 at 0845 with the CNO (Chief Nursing Officer) revealed the son became upset when the nurse was going to give Tramadol. Interview revealed the son believed the medication had contributed to his mother's rapid response (emergency response) on 05/25/2018. Interview revealed "we should have called the physician in front of the son that evening to clarify the medication before giving the Ultram (Tramadol)".

NC00148598
NC00149649