HospitalInspections.org

Based on interview and record review, the facility failed to ensure that drugs which belonged to the patient and were allowed for use were administered in accordance with the orders of the practitioner responsible for the patient's care, accepted standards of practice, Federal law and approved policies and procedures for 1 of 10 sampled patients (#1)

Findings:

A review of the medical record of patient #1 was performed. The patient was admitted to the Clinical Decision Unit of the hospital at 01:51 AM on 9/21/12. Physician orders of 9/21/12 at 6 AM read, "Felbamate Q6hr (every six hours) . . . . Pt (patient) own meds." Physician orders of 9/21/12 at 11:42 AM read, "Med - nonformulary & Pt own med . . . . Felbatol (1200 MG) 2 tablets BID (twice a day)." Felbatol is an ant-seizure medication.

The History & Physical, dictated on 9/21/12 at 1:22 PM, read, "Present medications . . . . Albuterol sulfate . . . Advair . . . Felbamate . . . Phenytoin . . . . Continue all home medications as dictated above."

The record revealed that Felbatol was administered on 9/21/12 and 9/22/12 as ordered. A nurse's note on 9/22/12 at 12:45 PM read, "Received pt to medical floor". Thus, the patient had left the Clinical Decision Unit at this time.

A nurse's note on 9/23/12 at 10 PM read, "Pt's (patient's) own med, Felbatol, not available to be given." A review of the Medication Administration Record confirmed this statement as it revealed that this medication was not given at any time during 9/23/12. A nurse's note on 9/24/12 at 11:02 AM (the next day) read, "Pts seizure medication found in CDU (Clinical Decision Unit) and brought up to med room, med given to pt as per MD (Medical Doctor) orders." This medication had been ordered on 9/21/12. Thus, orders had not been followed as written on 9/23/12.

A review of facility policy "Medication Management Plan" revealed the following: "Medication shall be administered by licensed personnel in accordance with Florida laws and regulations governing such acts. This includes . . . . nurses proper licensed and certified to administer medication in their respective professional area". Since the patient had not received Felbatol on 9/23/12, the nurse did not comply with Federal regulations 482.23(c)(1) which specify that medications be administered to patients per physician order.

During an interview of the Director of Quality at approximately 5 PM she confirmed the preceding.