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Based on record review and interview, the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care of each patient as evidenced by failing conduct an assessment prior to and after administering PRN medications for 3 of 3 records reviewed for PRN medications (Patient #2, 3, 4).
Findings:

Review of the hospital policy titled, Medication Management, revealed in part that PRN medications administered will be documented on the patient's MAR with cause and effect noted.

Patient #2
Review of the electronic medical record revealed the patient had a physician order for Vistaril 50mg three times daily PRN anxiety.

Review of the patient's MAR for March 2023 revealed the patient received Vistaril 50mg PRN on the following dates:
- 03/19/23 at 8:33 p.m. Nurses notes indicated the PRN medication was given because the patient was paranoid. There was no documented assessment after administration of the PRN medication to evaluate effectiveness.
- 03/18/23 at 8:18 p.m. The record failed to have documented evidence of an assessment prior to or after administration of the PRN medication.
- 03/16/23 at 8:28 p.m. The record failed to have documented evidence of an assessment prior to or after administration of the PRN medication

Patient #3
Review of the electronic medical record revealed the patient had a physician order for Vistaril 50mg three times daily PRN for anxiety

Review of the patient's MAR for March 2023 revealed the patient received Vistaril 50mg PRN on the following dates:
- 03/14/23 at 8:45 p.m. The record failed to have documented evidence of an assessment prior to or after administration of the PRN medication.
- 03/13/23 at 9:15 p.m. The record failed to have documented evidence of an assessment prior to or after administration of the PRN medication.

Patient #4
Review of the electronic medical record revealed the patient had a physician order for Vistaril 50mg three times daily PRN for anxiety

Review of the patient's MAR for March 2023 revealed the patient received Vistaril 50mg PRN on the following dates:
- 03/15/23 at 8:43 p.m. The record failed to have documented evidence of an assessment after administration of the PRN medication to ensure effectiveness.
- 03/13/23 at 8:32 p.m. The record failed to have documented evidence of an assessment prior to or after administration of the PRN medication.
- 03/12/23 at 9:24 p.m. The record failed to have documented evidence of an assessment prior to or after administration of the PRN medication.

Further review of the patient's medical record revealed a physician order for Benadryl 50mg/Prolixin 5mg intramuscular every 8 hours PRN agitation. The patient's March 2023 MAR revealed the patient received the above PRN injection on 03/07/23 at 12:25 p.m., but there failed to be a documented assessment of the patient prior to or after the administration of the PRN injection.

On 03/21/23 at 3:00 p.m., interview with S1QA Director confirmed that nursing assessments should be performed prior to and after administration of PRN medications. S1QA Director further confirmed that the above patient medical records lacked the nursing assessments prior to and/or after PRN medication administration.