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SENTARA MARTHA JEFFERSON HOSPITAL
ADMINISTRATION OF DRUGS
Tag No.: A0405
Based on medical records review and interviews, the facility failed to administer pain medication, as ordered, to Patient #3.
The findings include:
Patient #3 presented to the FSED (free standing emergency department) with a pain rating of five (5) out of ten (10). Staff Member #7 placed an order for Tylenol 650 mg (milligrams) at 3:39 PM. That order was canceled at 3:39 PM. Another order was placed for Tylenol 650 mg at 3:43 PM. Review of Patient #3's medical record indicated that this order was canceled at 4:00 PM. There was no documentation of the administration of Tylenol and/or any other pain medication to Patient #3 while in the FSED or a reason for the cancellation of the second order.
In an interview on December 17, 2024, Staff Members #7, #8 and #9, neither staff could recall why the Tylenol was not administered or why the order was canceled twice. Staff Member #9 indicated that the FSED was unusually busy that day and that perhaps the medication administration was missed.