HospitalInspections.org

Based on document review and interview, it was determined that the facility staff failed to document medication administration accurately for one (1) of nine (9) patients, Patient # 1.

The findings include:

A medical record review for Patient # 1 on March 14, 2019 at 8:30 a.m. revealed the patient arrived with parent at the Emergency Department (ED) at 1:01 a.m. with complaint of fever. Triage began at 1:08 a.m. Patient # 1 received an Acuity/Emergency Severity Index (ESI) of 2 at 1:25 a.m. An order was placed by the Physician at 1:30 a.m. for Tylenol liquid solution 60.8 mg at 1:30 p.m. Documentation by Staff Member # 15 at 1:31 a.m. reads: "medication given, Tylenol liquid solution 60.8 mg, route oral, scheduled time 1:31 a.m." Patient # 1 was taken to a room in the ED at 1:45 a.m. Documentation by Staff Member #15 at 1:57 a.m. reads in part: "Pt's dad reports pt had received dose of Tylenol already but was not sure of name of nurse who administered it. Place on monitor at this time. Awaiting MD."

An interview with Staff Member #12 on March 14, 2019 at 9:00 a.m. revealed "It looks like the medication was given in triage and the nurse did not sign the medication out." When asked how the nurse gets the medication from the "accudose" (the facility's electronic medication expensing system) without signing, Staff Member # 12 stated: "they can override the system." When Staff Member # 12 was asked about the documentation by Staff Member # 15, Staff Member # 12 stated: "It looks like that was the nurse assigned to the patient in the ED and the medication was given by the nurse in triage."

During an interview with Staff Member # 10 on March 14, 2019 at 10:00 a.m. when asked about the documentation by Staff Member # 15, Staff Member # 10 stated: "it looks like Staff Member # 15 did not administer the medication and should have documented administered by the nurse giving the medication."

According to standards of practice, documentation is expected to occur after actual administration of the medication to the patient; advance or no documentation is not only inappropriate, but may result in medication errors. Proper documentation of medication administration actions taken and their outcomes is essential for planning and delivering future care of the patient.

The findings were discussed with Staff Members # 2, # 4, # 5 and # 13 during the exit interview on March 14, 2019 at 12:00 p.m.