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Based on record review and interview it was determined that the facility failed to administer physician ordered medication for 1 (patient #1) of 5 records reviewed. Failure to administer physician ordered medication has the potential to lead to decline in the patient's current condition.


Findings:

A review of the Emergency Department Nurses Notes dated 02/20/2012 at 1:40 PM (the date of admission) revealed that patient #1 arrived via Emergency Medical Services to the Emergency Department after a fall at his residence. The note stated the patient now has a laceration to the forehead and left hip pain. The physician noted the patient's pain was a 6 on a scale of 1-10. The patient was diagnosed with a Left Hip Fracture. An order was written by the physician for Percocet 5/325 milligram (mg) 1 by mouth every 4 hours as needed for pain at 4:55 PM on 02/21/2012. An additional order was written for Morphine Sulfate 2-4 mg intravenous (IV) every 6 hours as needed for pain on the admission orders. The patient was medicated for pain at 8:24 PM with Morphine 2 mg IV. The reassessment indicated the pain was improved with decreased facial grimacing. Further record review failed to reveal that the first order of Percocet was ever administered.

In an interview conducted with the Risk Manager on 04/30/2012 at 1:00 PM it was acknowledged the medication was not given for pain until the Morphine was given at 8:24 PM.