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32059

Based on medical record review, staff interview, and review of the hospital medication administration policy and procedure. It was determined nursing failed to administer medication in accordance with hospital policy. This affected one of ten medical records reviewed (Patient #3). The active census at the time of the survey was 132.

Findings include:

The medical record indicated Patient #3 was admitted on 04/16/14 for treatment of Chronic Obstructive Pulmonary Disease (COPD) exacerbation. Review of the physician's admission orders dated 04/16/14 included Norco (narcotic pain medication) 325/5 mg by mouth every six hours and Ativan (anti-anxiety) 1 mg by mouth every night. Nursing documentation on the medication administration record indicated the pain medication was administered as prescribed by the physician. On 4/20/14 at 12:00 PM the medical record indicated the pain medication was held by the nurse due to weakness and the physician was notified. Telephone orders on 4/20/14 at 12:00 PM included a medication administration change for Norco (pain medication) to every six hours as needed for pain.

Physician's progress notes dated 04/20/14 and 04/21/14 documents to discontinue Ativan. Nursing documentation dated 04/21/14 at 10:40 AM indicated that Ativan 0.5 mg was administered IVP per order. The medical record lacked evidence that a new Ativan order was obtained and/or written after the medication had been discontinued per the physician(s). The medication administration record confirmed the Ativan was administered on 04/21/14 at 10:42 AM. This finding was confirmed with Staff A and B on 06/17/14 at 3:20 PM.

Review of the hospital policy and procedure for medication administration effective 03/21/14 states before administering a medication, the LIP or appropriate health care professional administering the medication will verify the medication is being administered at the proper time, in the prescribed dose, and the correct route.




This deficiency substantiates the allegation in Substantial Allegation Number OH00074729.