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Based on record reviews and interviews, an order for Risperidone 1 mg was not administered as ordered for one of one patients (patient #1) who had a history of mental illness and was admitted to the hospital because she attempted suicide.

Findings included:

Record review of Patient #1's Admission Psychiatric Evaluation, dated 05/02/12, revealed Patient #1 was a "17 year old female admitted to the facility due to a suicide attempt at her residential facility. Her current out of hospital medications included Risperidal (generic brand is Risperidone)1 mg at bedtime. She had reported depression with suicidal ideation for the past week. She told the psychiatrist she continued to have suicidal ideation with a plan to use whatever she could. She had 16 past suicide attempts".

Record review on 07/09/12 of Patient#1's physician orders, dated 05/02/12 at 1835 revealed the following: Risperidone 1 mg by mouth at bedtime, first dose to be given on 05/02/12. The order was noted by Licensed Vocational Nurse (LVN) #1 at 2211.

Record review on 07/09/12 of Patient #1's Medication Administration Record (MAR) for 05/02/12 revealed Risperidone 1 mg by mouth at bedtime, first dose on 05/02/12, was noted by LVN #1 and documented as not available.

Continued record review of Patient #1's medical record revealed no further documentation to indicate this medication was administered nor was there any documentation reflecting why the medication was not administered.

Interview on 07/09/12 at 12:20 with LVN #1 confirmed that he was the nurse who noted the order. He stated if they were out of the medication, he would have called the nursing supervisor and the phone call should have been documented. He stated the facility normally has the medication (Risperidone) and if they didn't have the medication, it would have been obtained from a local 24 hour pharmacy. He was unable to state why there was no further documentation regarding the medication being unavailable. He was unable to confirm whether Patient #1 received the medication as ordered.

Interview on 07/09/12 at Registered Nurse #1, Nursing Supervisor for the Adult Unit, revealed that if a medication were not available, the medication nurse would be expected to contact the nursing supervisor for the unit who would have access to the "night-locker" during non-pharmacy hours. She further stated that if the medication were not available in the "night-locker", the nursing supervisor would obtain the medication from a local 24 hour pharmacy to ensure the medication was administered as ordered.

Interview on 07/09/12 at 2:20 PM with the Director of Risk Management revealed this medication issue was not identified and/or documented as a medication error. She indicated the facility completes quality assessment reviews on a percentage of patient charts. She confirmed that medications were always available because a local pharmacy will deliver to the facility 24 hours a day.