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ST ELIZABETH'S MEDICAL CENTER
No Description Available
Tag No.: A0404
Based on documentation review it was determined the Hospital failed to ensure drugs and biologicals were administered in accordance with orders in one of one applicable patient record reviewed.
Findings included:
1.) Review of Physician Orders dated 1/3/10 at 11:00 AM indicated a protocol was written for the Patient to receive Patient Controlled Analgesia (PCA) with Morphine.
2.) Review of the Patient's Medication Administration Record indicated that the Patient did not receive the PCA, nor was the order transcribed and there was no order to discontinue the PCA.
3.) The Assistant Director of the Mother/Baby Unit was interviewed intermittently during the on site investigation. She said sometimes the doctors will write orders for PCA in anticipation of a patient needing it. However review of the Patient's medical record indicated that the Patient probably did not need the PCA because of the Duramorph used with spinal anesthesia. However, she understood an order was written and not discontinued.