HospitalInspections.org

Based on review of policy and procedure, medical record, and staff interview, it was determined the CAH failed to ensure that nurses follow the policy and procedure for labeling "To Go Pack " medications given to one of one patient at time of discharge. (patient # 5)

Findings include:

Review of policy and procedure titled "To Go Pack" required: "...the medication label will be attached to each bottle containing medication by pharmacy. Requirements mandated by the statues such as name, strength, dosage form and quantity of the drug...remaining requirements must completed(sic) prior to dispensing the medication to the patient: a. patient name b. date of dispensing c. directions for use d. printed name of ordering provider...."

Review of the discharge summary paperwork identified a physician order for the "To Go Pack" of five tablets of Vicodin. The nursing record revealed the Vicodin was given to the patient. However; there was no documentation on the discharge instructions related to the Vicodin given to the patient. The facility did not follow their policy and procedure for dispensing of the "To Go Pack".

Employee # 17 confirmed during and interview conducted on 8/6/14 the staff did not follow the facility policy and label the "To Go Pack " medication prior to giving to the patient.

Based on hospital policy and procedure, medical records and interview, it was determined the CAH failed to ensure the nursing staff meet the patient needs for pain reassessment for one of one patient (patient #5).

Findings include:

Hospital policy titled "Management of Acute and Chronic Pain" requires: "...After any method of pain control has been used, reassessment will occur at frequent intervals...until pain is controlled to the patient's satisfaction...Notify the physician of ineffective pain management...."

Patient #5 was seen in the emergency department on August 22, 2012 after a motor vehicle accident. The patient received three doses of Morphine 5mg (milligrams) intravenously at 1945, 2035, and 2300 for complaints of pain. There was no documentation of any pain reassessment.

Employee #4 confirmed during interview the nursing staff did not follow the facility policy for pain reassessment.