HospitalInspections.org

Based on record review and interviews, the facility failed to ensure drugs are administered in accordance with the orders of the practitioner in 1 of 10 (Patient #9) sampled patients.

Findings include:

Review of the record revealed patient #9 was admitted to the freestanding emergency department (ED) with a diagnosis of acute headache without meningeal signs, local rash on the right lateral back, likely reaction to insect bite, and rule out (r/o) local infection/cellulitis. Review of the record revealed the patient was then transferred and admitted to the facility.

On 04/22/17 at 8:00 AM, a peripheral intravenous (IV) was started in the patient's left arm.

On 04/22/17 at 5:00 PM, the nurse administered the first dose of the physician's order of 900 milligrams (mgs) Clindamycin intravenous (IV) piggy back to be infused over a 30 minute period; a total of 3 doses to be given every 8 hours.

On 04/23/17 at 1:30 AM, the second dose was scheduled.

On 04/23/17 at 2:00 AM, review of the nurse's note revealed the medication was not given, as there was no IV access. The entire second dose was not given because of this.

On 04/23/17 at 11:52 AM, the IV was re-started and the third dose was given (9 hours later). Due to the delay in re-starting the IV, the patient received only two of three doses (doses one and three) while an in-patient. The record failed to reveal the physician was notified of the delay in administering the medication.

The patient was discharged with a prescription of Clindamycin 300 mg per oral three times per day for 6 days.

Review of the grievance, complaint and incident report logs failed to reveal any entry regarding the failure to administer the Clindamycin according to the physician's orders.

During an interview with the Director of the Neuro Unit, on 06/07/17 at 10:00 AM, she provided a copy of an email sent to her on 04/24/2017 by the Nursing Supervisor. Review of the email revealed a complaint was submitted by Patient # 9's husband. The email listed the complainant's concerns and a statement that the nursing supervisor "would be reporting his concerns to the highest level". The Director of the Unit stated that she filed this email in her email notebook and did not notify the Risk Manager or initiate an incident report.

On 06/07/17 at approximately 10:30 AM, the Risk Manager, Director of Quality Improvement, Director of the Neuro Unit, Nurse Manager of the Neuro Unit, Director of Pharmacy, and the Pharmacy Clinical Manager & Specialist, each confirmed the nurse failed to administer the Clindamycin according to the physician's orders.