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NORTH AUSTIN MEDICAL CENTER
ADMINISTRATION OF DRUGS
Tag No.: A0405
Based on a review of facility documentation and staff interviews, the facility failed to follow the standards of care by failing to document the starting of an Intravenous (IV) to administer medications in 1 of 4 Emergency Department patient charts reviewed.
FINDINGS WERE:
The Emergency Department record of Patient #1 included no documented evidence of the insertion of an IV prior to the administration of IV medications.
The Texas Administrative Code Examining Boards Part 11, Texas Board of Nursing Chapter 217, Licensure, Peer Assistance, and Practice Rule §217.11 Standards of Nursing Practice
(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall:
(A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; ...
(D) Accurately and completely report and document:
(i) the client's status including signs and symptoms;
(ii) nursing care rendered;
(iii) physician, dentist or podiatrist orders;
(iv) administration of medications and treatments;
(v) client response(s); ...
Patient #1 was treated in the Emergency Department (ED) on 2/13/2022 for abdominal pain, vomiting, and bloody stools. The patient had a pain level of 7 on a scale of 1-10. Review of the medication administration record reflects that 2/14/22 at 03:30 am Dilaudid (hydromorphone-narcotic pain medication) was given IV by Staff #10. There was no documentation of the IV being started on the patient.
During an interview with RN #6 he stated that nurses are required to document when they start an IV. This should include where the IV was placed, number of attempts, date, and time.
RN #6 validated that there was no documentation of the IV being started in the medical record.
CONTENT OF RECORD: ORDERS,NOTES,REPORTS
Tag No.: A0467
Based on a review of facility documentation and staff interviews, the facility failed to document the starting of an Intravenous (IV) to administer medications in 1 of 4 Emergency Department patient charts reviewed.
FINDINGS WERE:
The Emergency Department record of Patient #1 included no documented evidence of the insertion of an IV prior to the administration of IV medications.
Patient #1 was treated in the Emergency Department (ED) on 2/13/2022 for abdominal pain, vomiting, and bloody stools. The patient had a pain level of 7 on a scale of 1-10. Review of the medication administration record reflects that 2/14/22 at 03:30 am Dilaudid (hydromorphone-narcotic pain medication) was given IV by Staff #10 . There was no documentation of the IV being started on the patient.
During an interview with RN #6 he stated that nurses are required to document when they start an IV. This should include where the IV was placed, number of attempts, date, and time.
RN #6 validated that there was no documentation of the IV being started in the medical record.