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Based upon review of 1 of 4 emergency department records out of a sample size of 11, emergency department policy and procedure and staff interview, the registered nurse failed to follow policy and procedure as evidenced by failing to 1) utilize the "code sheet" for documentation of emergency medications and treatments provided to patient #3, and 2) document an evaluation of patient #3's condition and the patient's response to interventions provided. Findings:

Review of the emergency department record for patient #3, a 50 year old female, arrived to the ED by ambulance on 07/26/10 at 1:30 PM. The patient arrived unresponsive, orally intubated and cardio-pulmonary resuscitation was in progress and administered by Emergency Medical Service Paramedics. Review of the documentation of RN S9's documentation on the Emergency Department Record revealed patient #3's initial cardiac rhythm was documented as "ventricular fibrillation" and 200, 300, 100 was written in below; however, there failed to be further documentation what the numbers were referenced to. At 3:05 PM, RN S9 documented Nitroglycerin was administered; however, the route and dosage failed to be identified.

Further review of patient #3's ED Record revealed the first entry documented by RN S9 was "Epi 2, Atr 2, Lidocaine, CBG 105. WSO (Winn Sheriff Department) reports pulseless on arrival. CPR (cardio-pulmonary resuscitation) started until EMS arrived. Found lying on floor in Walmart, unwitnessed." Further review of RN S9's documentation revealed the following: "1355 (1:55 PM) or thereabout, MD went to room" "1400 (2:00 PM) Vent setting changed to 60% FIO2" "1401 (2:01 PM) Reported ABG to MD via phone. He stated 'I saw resp (respiratory) in hall and told them to change to 60 %. Ask MD to make sure he was aware of 7.12 ph, He stated I am aware no need for further treatment at this time." "1407 (2:07 PM) MD arrives to room" "1408 (2:08 PM) 150 approx from Foley, specimen collected." "1412 (2:12 PM) To CT no plantar reflex" "1422 (2:22 PM) Monitor in place MD aware that patient is posturing". At 5:03 PM, patient #3 was transferred to another acute care hospital.

Review of ED physician S17's documentation revealed the following medications were administered to the patient: 2:25 PM: Rocephin 2 Grams Intravenous Piggy Back (IVPB) 2:30 PM: Ativan 2 milligrams IV with a second dose administered at 3:06 PM, 2:23 PM: Plavix 300 milligrams down Nasogastric Tube, 2:50 PM Levaquin 750 milligrams IVPB, 2:54 PM: Regular Insulin 4 units IV, 2:55 PM: Lopressor 5 milligrams IV with a second dose repeated at 3:10 PM, 2:57 PM: Lasix 40 milligrams IV. At 3:05 PM a Nitroglycerin drip was initiated at 5 micrograms.

Interview with the ED nurse manager, S8, on 08/02/10, 2:15 PM, revealed after reviewing patient #3's ED record, S8 stated RN S9 should have utilized the ED "code sheet" to document the medications and interventions provided to patient #3 while in the ED. Interview with RN S9 on 08/02/10, 2:35 PM, revealed when questioned about the ED record documentation, RN S9 replied the medications listed at the top of the ED record, Epi (Epinephrine), Atr (Atropine), and Lidocaine, were the medications administered by EMS personnel prior to the patient's arrival. When RN S9 was asked about the documentation of the medications and interventions patient #3 received while in the ED, S9 replied when the patient initially presented she did not have time to record all the medications and interventions the patient received.

Review of the ED policy and procedure "Medication Administration and Documentation: c...record desired therapeutic effects, precautions taken, and untoward effects." "4. Responsibilities in Medication Administration: c. The administering person who prepares the medication(s) administers them and charts them as being given. Medications should be charted immediately after being given."

The Registered Nurse (S9) failed to follow hospital policy and procedure and document: 1) medications administered to the patient as ordered by the physician, and 2) interventions (ie, defibrillation, initiation of IV access sites) for patient #3 while she was a patient in the Emergency Department.