HospitalInspections.org

Based on medical record review and interview, it was confirmed medications were not administered per Physician's orders, and not administered in accordance with approved medical staff policies and procedures, for 1 of 4 sampled patients and 12 reviewed patients(Patient #1).

Findings:

A review of the closed record for Patient #1 revealed numerous discrepancies regarding the administration of medications throughout the patient's stay in the facility. The medical record to include Nurse's Notes, Medication Administration Records (MARs) and the computerized Pharmacy distribution reports were reviewed with the Chief Nursing Officer (CNO), Director of Quality and the Pharmacist on 3/10/2011 beginning at 1:05 PM. It was confirmed the following concerns were identified:

a.) 2/23/2011: Midnight: Morphine 45 milligrams (mg) not documented as administered. Confirmed with the CNO and Quality Director the medication was pulled at 10:21 PM for the midnight dose as documented on the computerized drug dispensing report.
b.) 2/22/2011: Ambien 5 mg x 2 PO (by mouth) Q (every) HS (bedtime/at hour of sleep), not administered per 9:00 PM dose. Confirmed with the CNO and Quality Director the medication was pulled as documented on the computerized drug dispensing report at 10:22 PM. Late administration.
c.) 2/18/2011: Morphine 45 mg PO not administered at midnight dose. Not initialed off on the MAR as administered. Confirmed with the CNO and Quality Director the medication was pulled as documented on the computerized drug dispensing report at 11:48 PM.
d.) 2/18/2011 Polyethylene Glycol (Miralax) not administered at 4:00 PM dose as not initialed as administered.
e.) 2/15/2011: Morphine 45 mg PO not administered at 6:00 PM dose. Not initialed off. Confirmed with the CNO and Quality Director the medication was pulled as documented on the computerized drug dispensing report at 5:41 PM.
f.) 2/12-13/2011: Morphine 45 mg PO indicated for administration at 12:00 noon documented as administered at 3:00 PM. (LATE), with no justification as to why it was late either in Nurse's Notes or elsewhere in the medical record. It was confirmed with the Chief Nursing Officer this was a House or hospital nurse on duty and not an Agency nurse. The 6:00 PM dose is circled as not given, but documented as given at 10:00 PM, Late Administration. Order changed with no indication of the midnight (12:00 AM) dose being administered, time was crossed off.
g.) 2/11/2011: Morphine 45 mg PO indicated for administration at 6:00 AM, confirmed not pulled per the computerized reports, however 45 mg pulled at 9:21 AM for the 10:00 AM administration. 3:00 PM, 45 mg pulled from the system at 3:20 PM. The 9:00 PM dose is marked off as not administered and the 12:00 AM midnight dose of 45 mg pulled and administered.
h.) 2/11/2011: Morphine dosage changed from 30 mg to 45 mg PO 4 times a day (QID). 9:00 PM dose crossed off without initials.

An interview was conducted with the Chief Nursing Officer on 3/10/11 at 1:16 PM. The interview revealed the noted order indicated above for 2/11/2011 was discontinued on 2/10/2010 at 8:50 PM per Physician's Orders. The order was changed to 45 mg PO QID (or every 6 hours). It was confirmed the indication of 06 is circled indicating the 6:00 AM dose was not given on 2/11/2011. The 10:00 AM dose was given as was the 3:00 PM dose. It was confirmed with the CNO the 7:00 PM dose was not given as indicated on the MAR. It was confirmed with the CNO and the Quality Director at 1:28 PM, through review of the medical record to include the Nurse's Notes and MARs, there was no indication regarding why the medications had been delayed in being administered up to 3 hours and then why the medication was administered exceptionally late.

Further review of the medical record and Pharmacy data revealed:
2/12/2011: Complaints of pain at 1:00 AM and 7:00 AM, with no other indications of pain monitoring for that day regarding break through pain.
2/13/2011: Complaints of pain at 4:00 AM; 10:00 AM and 2:00 PM. With no other indications of pain monitoring of pain for that day regarding break through pain.

An interview was conducted with the patient's Physician on 3/10/2010 at 12:50 PM. Per the physician, the patient indicated throughout the entire hospitalization, he wanted any medication which was sedating. It was confirmed the patient takes pain medication at home from a previous accident.

Throughout the interviews with the Director of Quality, Chief Nursing Officer and Pharmacist, it was concluded the documentation of medication administration by the nursing staff was not consistent; leading to the belief on numerous occasions that medications had not been administered. It was also confirmed dosage times had been modified without a clear explanation as to the justification of the change, nor the initials of the person administering the medication or the time when administered.

Per the hospital's Pharmacy Department policies #4.2.05, "Documentation on the patient's Medication Administration Record (MAR) should be clear and unambiguous regarding administration, wastes, and doses not given. The process should be consistent throughout the hospital. An example of a clear process is listed below:
After a medication has been given, the time administered is marked through with one line and the nurse's initials are recorded next to the time."

Based on medical record review and interview, it was confirmed that for 1 of 12 patients (Patient #1) the facility failed to document the administration of medication as per the facility's policy and procedure.

Findings:

A review of the closed record for Patient #1 revealed numerous discrepancies regarding the administration of medications throughout the patient ' s stay in the facility. The medical record to include Nurse's Notes, Medication Administration Records (MAR's) and the computerized Pharmacy distribution reports were reviewed with the Chief Nursing Officer (CNO), Director of Quality and the Pharmacist on 3/10/2011 beginning at 1:05 PM. It was confirmed the following concerns were identified:

a.) 2/23/2011: Midnight: Morphine 45 mg not documented as administered. Confirmed with the CNO and Quality Director the medication was pulled at 10:21 PM for the midnight dose as documented on the computerized drug dispensing report.
b.) 2/22/2011: Ambien 5 mg x 2 PO (by mouth) Q (every) HS (bedtime/at hour of sleep), not administered per 9:00 PM dose. Confirmed with the CNO and Quality Director the medication was pulled as documented on the computerized drug dispensing report at 10:22 PM. Late administration.
c.) 2/18/2011: Morphine 45 mg PO not administered at midnight dose. Not initialed off on the MAR as administered. Confirmed with the CNO and Quality Director the medication was pulled as documented on the computerized drug dispensing report at 11:48 PM.
d.) 2/18/2011 Polyethylene Glycol (Miralax) not administered at 4:00 PM dose as not initialed as administered.
e.) 2/15/2011: Morphine 45 mg PO not administered at 6:00 PM dose. Not initialed off. Confirmed with the CNO and Quality Director the medication was pulled as documented on the computerized drug dispensing report at 5:41 PM.
f.) 2/12-13/2011: Morphine 45 mg PO indicated for administration at 12:00 noon documented as administered at 3:00 PM. (LATE), with no justification as to why it was late either in Nurse's Notes or elsewhere in the medical record. It was confirmed with the Chief Nursing Officer this was a House or hospital nurse on duty and not an Agency nurse. The 6:00 PM dose is circled as not given, but documented as given at 10:00 PM, Late Administration. Order changed with no indication of the midnight (12:00 AM) dose being administered, time was crossed off.

An interview was conducted with the Chief Nursing Officer at 1:16 PM. It was confirmed with the CNO and the Quality Director at 1:28 PM, through review of the medical record to include the Nurse's Notes and MAR's, there was no indication regarding why the medications had been delayed in being administered up to 3 hours and then why the medication was administered exceptionally late.

Throughout the interviews with the Director of Quality, Chief Nursing Officer and Pharmacist, it was concluded the documentation of medication administration by the nursing staff was not consistent; leading to the belief on numerous occasions that medications had not been administered. It was also confirmed dosage times had been modified without a clear explanation as to the justification of the change, nor the initials of the person administering the medication or the time when administered.

Per the hospital's Pharmacy Department policies #4.2.05, "Documentation on the patient ' s Medication Administration Record (MAR) should be clear and unambiguous regarding administration, wastes, and doses not given. The process should be consistent throughout the hospital. An example of a clear process is listed below:
After a medication has been given, the time administered is marked through with one line and the nurse's initials are recorded next to the time."