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Based on record review and interview the hospital failed to ensure patient rights by giving a medication the family refused. In one out of ten patients sampled (#1)

Findings:

Record review of Patient #1's, Nursing Notes dated 04/20/19 by the unit Charge RN. The son and wife of patient #1 requested that Ativan not be given to the patient again as it caused severe confusion.

Record Review of Patient #1's Medical Record dated 4/20/19 showed that an allergy for Ativan was documented on the Allergy section of Medication Administration Record (MAR). The system did not log the staff member name just the date. It was also noted on 4/20/19 that the patient's family requested he not receive the medication Ativan due to it causing severe confusion written by Charge Nurse.

Record review of Patient #1's, MAR on 4/23/19 at 00:59 AM revealed that the RN Employee #2 administered Ativan and documented an override to bypass the warning to not administer due to allergy.

Record review of MAR on 4/24/19 at 8:50 PM revealed that the RN Employee #2 administered Ativan and documented an override to bypass the warning to not administer due to allergy.

Record review of the facility's policy titled, "Medication: Administration, General", dated 06/19 section procedure for nursing, showed the following:

· Verify drugs to be administered with the prescriber's order. Refer to the MAR and ensure that the dose is correct, and that allergy, sensitivity, or diagnosis does not contraindicate use of the drug.
· The individual administering the medication should complete the following:
· Verifies that no contraindication exists.
· If the medication is not given (e.g. it may be held at the authorized personnel's discretion or refused by the patient), document in MAR,

Interview with Quality Director and Quality Manger on 7/3/19 at 09:00 AM. The Quality Manager stated, "There is no policy for nurses, for adding an allergy after a medication has been ordered". "Nor, is there is a process for holding a medication or discontinuing it after an allergy has been documented".

Based on record review and interview of facility personnel, the facility failed to ensure prior to administering a medication that the patient did not have a documented allergy to the medication for one of ten patients sampled (#1)
Findings:

Record Review of Patient #1's Medical Record showed Ativan was ordered on 4/18/19 and given at twice on 04/18/19 at 07:00 AM and 11:00 PM for agitation.

Record Review of Patient #1 Medical Record dated 4/20/19 showed that an allergy for Ativan was documented on the Allergy section of Medication Administration Record (MAR). The system did not log the staff member name just the date.On 4/20/19 the charge nurse noted that the patient's family requested he not receive the medication Ativan due to it causing severe confusion.

Record review of Patient #1's MAR on 4/23/19 at 00:59 AM revealed that the RN Employee #2 administered Ativan and documented an override to bypass the warning to not administer due to allergy.

Record review of Patient #1's MAR on 4/24/19 at 8:50 PM revealed that the RN Employee #2 administered Ativan and documented an override to bypass the warning to not administer due to allergy.

Record Review of Patient #1's chart showed that Employee #2 did not call the Medical Doctor to verify order before giving the medication.

Interview with Quality Director and Quality Manger on 7/3/19 at 09:00 AM. The Quality Manager stated, "There is no policy for nurses, for adding an allergy after a medication has been ordered". "Nor, is there is a process for holding a medication or discontinuing it after an allergy has been documented".

Based on record review and interview the facility failed to ensure that the pharmaceutical services were meeting all the patients needs by not having a policy in place to prevent patient's from receiving a medication that has been noted after admission as an allergy.

Record review of the facility's policy titled, "Medication: Administration, General", dated 06/19 showed the following:

The pharmacist is responsible for verifying the accuracy, completeness, and appropriateness of the medication ordered by the physician.

Record review of the facility's policy titled, "Medication: Administration, General", dated 06/19 section procedure for nursing, showed the following:

Verify drugs to be administered with the prescriber's order. Refer to the MAR and ensure that the dose is correct, and that allergy, sensitivity, or diagnosis does not contraindicate use of the drug.
The individual administering the medication should complete the following: verifies that no contraindication exists.
If the medication is not given (e.g. it may be held at the authorized personnel's discretion or refused by the patient), document in MAR.

Interview with Employee #3 Pharmaceutical Clinical Manager on 7/3/19 at 10:30 AM. Employee #3 explained that the Pharmacist who gets the order is supposed to acknowledge it. This did not occur and each pharmacist after that also bypassed the order. When asked why this occurred and why the Ativan was not taken out of the system after it was written that the patient was allergic to it. She said that the pharmacist should only be bypassing the acknowledgement if he/she had a pending clarification. When asked why after an allergy was entered did the pharmacist not put the medication on hold. She said that the pharmacist should have. The Pharmaceutical Clinical Manager was asked for the policy on allergy entry after admission during stay. She stated, "We do not actually have a policy for that".