HospitalInspections.org

Based on review of policies and procedures, review of Emergency Department records and interview, it was determined staff failed to follow policy to reassess patients' responses to medication administration in 5 (#1, #3, #5, #8 and #10) of 10 (#1-#10) patient records. Failure to reassess patients' responses to medication administration did not assure interventions (i.e. medication administration) were effective. The failed practice was likely to affect all patients receiving medications in the Emergency Department. Findings follow:
A. Review of policy, "Medication Administration and Documentation" presented by the Emergency Department Nurse Manager on 10/08/15 revealed assess and document the patient's response to all medications (PRN (as needed) one-time dosages) other than routine medications.
B. Review of the Emergency Department record for Patient #1 revealed cyclobenzaprine (Flexeril) 10 mg (milligrams) and ketorolac (Toradol) 15 mg were administered at 0704 on 09/24/15. There was no evidence a reassessment of the medications' effectiveness was conducted.
C. Review of the Emergency Department record for Patient #3 revealed Morphine 4 mg was administered at 2255 on 09/25/15 and Hydromorphone 2 mg was administered at 2050 on 09/25/15. There was no evidence a reassessment of the medications' effectiveness was conducted.
D. Review of the Emergency Department record for Patient #5 revealed Mylanta 30 ml (milliliter) and Xylocaine Viscous 2% 10 ml were administered at 0017 on 09/26/15. There was no evidence a reassessment of the medications' effectiveness was conducted.
E. Review of the Emergency Department record for Patient #8 revealed Morphine 2 mg was administered at 0909 on 09/26/15 and Morphine 4 mg was administered at 0934 on 09/26/15. There was no evidence a reassessment of the medications' effectiveness was conducted.
F. Review of the Emergency Department record for Patient #10 revealed pantoprazole 40 mg was administered at 1953 on 09/26/15 and Zofran 4 mg was administered at 1507 on 09/26/15. There was no evidence a reassessment of the medications' effectiveness was conducted.
G. Findings listed as B-F were verified by the Registered Nurse Physician Educator Support during record review on 10/08/15 at 1215.