HospitalInspections.org

Based on a review of documentation and interview, the facility failed to ensure that drugs were administered in accordance with hospital policies.

Findings included:

Facility based policy number PHR-175 entitled, "USE OF PRN MEDICATIONS" stated in part,
"1.0 STATEMENT OF PURPOSE:
Orders for PRN medications must be clear and concise to ensure patients are effectively and accurately treated for the desired condition.
2.0 STATEMENT OF POLICY:
The Pharmacy in conjunction with the facility's Medical Staff and Administration will advocate the use of
·PRN medications provided certain guidelines are followed ...

4.0 PROCEDURE: ...
4.2 The nurse who administers the "PRN" medication will document in the appropriate section of the patient record. the purpose for which the medication was given and whether the patients outcome was effective or ineffective in response to the medication."

Review of Child and Adolescent medication administration records revealed the following:
* Patient #1 had Haldol 10 mg PO PRN [pro re nata which means as the need arises] TID ordered for agitation and severe anxiety on 10/12/24 at 1730. Haldol 10 mg was administered on the following dates and times: 10/12: Haldol 10 mg at 1730 (PRN) and 10/13 Haldol 10 mg at 0445 (PRN). The effectiveness of these PRN doses was not documented, and there was no documented purpose or rationale related "agitation and severe anxiety" for administering this medication in the medical record. A note on 10/13/24 at 0445 stated, "Pt came out into hallway with pants halfway down. Pt re-directed to her room. PRN Haldol given. Staff will monitor."
This notes does not describe agitation and severe anxiety behaviors.
* Patient #19 received PRN doses of a psychotropic medication of Thorazine 100 mg PO ordered to address agitation and aggression on 10/21/24 at 1050 and 10/22/24 at 1530. The effectiveness of these PRN doses was documented, however there was no documented purpose or rationale related to "agitation and aggression" for administering the medication in the medical record.
* Patient #20 received PRN doses of a psychotropic medication Zydis 5 mg PO ordered to address agitation on 10/22/24 at 1040 and 1415. The effectiveness of these PRN doses was documented, however there was no documented purpose or rationale related to "aggression" for administering the medication in the medical record. The only documentation as to rationale was a nurse note on 10/22 at 0900 stating the patient was agitated and the patient took the PRN (this was documentation over an hour and half prior to the actual administration of the Zydis).

Due to the lack of documentation, to reflect the purpose or rationale for administered PRN psychoactive medications in the medical record, it cannot be established that the PRN medications were being administered to address the indicated behaviors/symptoms in the original physician order (such as agitation, anxiety, and/or aggression) or that the medications were effective in addressing those symptoms/behaviors.

The above findings were verfied with staff member #2 on 10/23/24.