HospitalInspections.org

Based on policy, medical record review and interview, the hospital failed to ensure medications were administered as ordered by a physician for 1 of 3 (Patient #2) sampled patients.

The findings included:

1. Review of the hospital policy "Medication Administration with Bar Code Administration" revealed, "...Purpose: To establish processes for safe medication administration and documentation...Medication Administration Procedure...2. Administration documentation will be done in real time...7. Anytime a medication is refused or held, document the reason on the MAR [medication administration record]. Notify the physican...for medications not administered..."

2. Medical record review for Patient #2 revealed a hospital admission date of 6/28/2022 with diagnosis of ischemic stroke. Physician orders dated 6/29/2022 revealed, Nystatin 100,000 unit/s mL [milliliter] oral suspension 5 mL by mouth, swish and swallow- four times per day. The Nystatin order was discontinued on 8/2/2022.

Review of the medication administration record (MAR) revealed the following seven (7) dates when the Nystatin was not administered four times per day, according to physician orders:
7/11/2022- 3 doses administered
7/12/2022- 3 doses administered
7/17/2022- 3 doses administered
7/19/2022- 3 doses administered
7/20/2022- 2 doses administered
7/22/2022- 3 doses administered
7/23/2022- 3 doses administered

There was no documentation the physican was notified of the missed Nystatin doses.

3. In an interview on 8/16/2022 at 1:20 PM, the Assistant Chief Nursing Officer verified the missed doses of Nystatin in the electronic medical record.