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Based on interviews and record reviews, the facility failed to ensure nursing services were provided to meet the ongoing educational needs of patients in 5 out of 5 records reviewed (patients #1, #2, #3, #6, and #8).

The failure resulted in patients' educational needs not being addressed.

FINDINGS

POLICY

According to the policy, Medication Administration and Documentation, nursing assessment will be applied to all phases of the medication transcription, administration, and documentation process. Patient medication education and the patient's response to medications being administered will be documented in the patient record.

REFERENCE

According to the Lippincott Manual of Nursing Practice 10th Edition, (pp. 179), nursing and patient care considerations related to medication administration include identifying problems in the use of medications, such as lack of knowledge about medications. Appropriate interventions for safe drug use include: verbal instructions should be reinforced with written instructions and patients should be encouraged to report adverse drug effects.

1. The facility did not ensure patients received medication education for medications administered during their Emergency Department (ED) visit.

a) Record review revealed, no documentation of patient medication education, nor did they contain the patient's response to medications administered while in the Emergency Department.

b) An interview with Registered Nurse #2 (RN) was conducted on 01/20/16 at 3:20 p.m. S/he stated the expectation of nursing staff was to educate all patients on the medications they received during their ED visit. Further, RN #2 stated s/he had received education in the ED of available educational resources for nursing staff to provide medication information to patients. RN #2 stated nursing staff are expected to document patient education in the patient's Electronic Medical Record (EMR).

c) A telephone interview with the Manager of Clinical Informatics (Employee #1) was conducted on 01/21/16 at 3:28 p.m. After medical records were reviewed, s/he stated the medical records did not contain any documentation of patient education of medications administered for patients #1, #2, #3, #6, and #8 during their ED visit.

An interview conducted at that same time with the Director of Quality (Employee #3) revealed the expectation of ED staff is to provide and document patient medication education in the EMR.