HospitalInspections.org

Based on document review and interview the facility failed to ensure that medication administration was appropriately monitored in 3 of 3 medical records reviewed (#7, #8, #11). Findings include:

On 7/29/14 at approximately 1500 during review of medical record #11 it was revealed that morphine was given on 6/13/14 at 2230 and 6/14/14 at 2110, no pain evaluation was documented before or after administering the pain medication to monitor the patient.

On 7/29/14 at approximately 1500 during an interview with staff E it was confirmed that monitoring of the patient's reaction to the pain medication was not documented in the medical record.

On 7/29/14 at approximately 1530 during review of medical record #8 it was revealed that Dilaudid was given on 5/9/14 at 0402 with a pain scale of 0 documented before giving the medication and no pain evaluation was documented after administering the medication to measure its effectiveness for the patient. On 5/8/14 at 2004 and 5/9/14 at 0043 oxycodone was given, no pain evaluation was documented before or after administering the medication to monitor the patient. On 5/10/14 at approximately 1030 patient #11 had a blood pressure of 179/112, clonidine was given at 1119, no follow up monitoring of the patient's blood pressure was recorded. The patient was then sent home at 1330 without documentation of the patient's blood pressure before being discharged.

On 7/29/14 at approximately 1545 during an interview with staff E it was confirmed that follow up monitoring for the dilaudid, oxycodone or clonidine had not been documented in the medical record.

On 7/29/14 at approximately 1600 during review of medical record #7 it was revealed that Morphine was given on 4/1/14 at 0140 no pain evaluation or monitoring was documented before or after administration of the pain medication. On 4/2/14 at 0741 and 1655 amlodipine was given. No follow up monitoring for the patient's blood pressure was recorded.

On 7/29/14 at approximately 1615 during an interview with staff E it was confirmed that Morphine and amlodipine follow up monitoring was not documented in the medical record.

Based on document review and interview the facility failed to ensure that medication administration was appropriately monitored in 3 of 3 medical records reviewed (#7, #8, #11). Findings include:

On 7/29/14 at approximately 1500 during review of medical record #11 it was revealed that morphine was given on 6/13/14 at 2230 and 6/14/14 at 2110, no pain evaluation was documented before or after administering the pain medication to monitor the patient.

On 7/29/14 at approximately 1500 during an interview with staff E it was confirmed that monitoring of the patient's reaction to the pain medication was not documented in the medical record.

On 7/29/14 at approximately 1530 during review of medical record #8 it was revealed that Dilaudid was given on 5/9/14 at 0402 with a pain scale of 0 documented before giving the medication and no pain evaluation was documented after administering the medication to measure its effectiveness for the patient. On 5/8/14 at 2004 and 5/9/14 at 0043 oxycodone was given, no pain evaluation was documented before or after administering the medication to monitor the patient. On 5/10/14 at approximately 1030 patient #11 had a blood pressure of 179/112, clonidine was given at 1119, no follow up monitoring of the patient's blood pressure was recorded. The patient was then sent home at 1330 without documentation of the patient's blood pressure before being discharged.

On 7/29/14 at approximately 1545 during an interview with staff E it was confirmed that follow up monitoring for the dilaudid, oxycodone or clonidine had not been documented in the medical record.

On 7/29/14 at approximately 1600 during review of medical record #7 it was revealed that Morphine was given on 4/1/14 at 0140 no pain evaluation or monitoring was documented before or after administration of the pain medication. On 4/2/14 at 0741 and 1655 amlodipine was given. No follow up monitoring for the patient's blood pressure was recorded.

On 7/29/14 at approximately 1615 during an interview with staff E it was confirmed that Morphine and amlodipine follow up monitoring was not documented in the medical record.