HospitalInspections.org

Based on record review and interview the facility failed to ensure drugs were administered in accordance with accepted standards of practice for two (2) of nine (9) sampled patient records (#2 and #8).

Findings:
Review of records reflected:
Record #2
Documented
Pain 12/06/09 @ 9:27pm pain 10
Medication Administered
Dilaudid 0.6mg @9:30pm 12/6/09
Dilaudid 0.4mg @9:40pm 12/6/09
Dilaudid 0.4mg @9:40pm 12/6/09
Dilaudid 0.6mg @9:50pm 12/6/09
Dilaudid 0.6mg @10:20pm 12/6/09
Reassessment
12/06/09 @10:30pm pain 4
The record failed to document reassessment of the pain prior to each administration of the pain medication.

Record #8
Documented:
Dilaudid administered @ 12:10pm 02/25/10 in PACU no documentation of Pain or reassessment of Pain
Interview with Risk Managers on 02/25/2010 at 4:00pm confirmed the records were accurate.