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FAIRFIELD MEMORIAL HOSPITAL 1
NURSING SERVICES
Tag No.: C1049
Based on document review and interview, it was determined for 1 of 10 (Pt #1) patients, the CAH failed to ensure medications were administered as ordered. This has the potential to affect all patients receiving care at the CAH.
Findings include:
1. On 04/10/23 at approximately 12:00 PM, Pt #1's record was reviewed. Pt #1 was admitted to outpatient services on 02/22/23 at 11:59 AM for a blood transfusion with a diagnosis of Anemia (low blood count). Pt #1's record included an order to transfuse 1 unit of PRBCs on 02/22/23. The order also included, "Pre-medicate with Tylenol 650 mg PO, Benadryl 25 mg PO, Give Lasix 20 mg IV after transfusion...." The "Transfusion report" indicated the transfusion started at 5:06 PM and was completed at 8:05 PM." Pt #1's record lacked documentation of the administration or refusal of the prescribed medications.
2. On 04/11/23 at approximately 10:15 AM, an interview was conducted the Assistant Director of Nursing (E #3). E #3 stated, "I reviewed the record (Pt #1's) and felt there should have been some other charting." E #3 agreed the chart lacked documentation that Pt #1 had taken the pre-medications at home prior to arriving at the hospital for the blood transfusion. E #3 stated, "I did discuss this with (E #1)."
3. On 04/11/23 at approximately 10:45, an interview was conducted with the Clinical Staff Educator/RN (E #5). E #5 stated, "I was asked to go in and verify the blood for (Pt #1). I talked to the pt. The pt told me (Pt #1) was very familiar with the blood transfusion process and takes the pre-medications at home before (Pt #1) comes to the hospital. Pt #1 had taken the Tylenol, Benadryl and Lasix before (Pt #1) came in." E #5 reviewed the record and agreed the record lacked documentation of the medications.
4. On 4/11/23 at approximately 3:00 PM, the CAH policy "Department of Pharmacy... Subject: Medication Administration.. Policy:... (Page 3)... The nurse administering the medication will stay with the patient until the medication is taken... (If a medication is held or refused, a notation is made on the patient's medication record.)"