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Based on review of 1 out of 14 medical record reviews, it was determined that the nursing staff failed to evaluate the patient's response to interventions.


During patient #1's stay at the hospital, the patient had been calm, cooperative but lacking realistic understanding of her ability to care for herself. She was not able to live independently, required assistance and supervision. The patient became upset at discharge regarding returning to the nursing home. Per the medical record, patient #1 was anxious and received Lorazepam 0.5 mg by mouth at 12:39 PM but no specific behaviors. On both the Nursing Transfer/Discharge Form and progress note written on April 4, 2014 at 11:00 AM that patient #1 also received Olanzapine (Zyprexa) 2.5mg IM ( intramuscular) for restlessness and agitation but again no specific behaviors were documented. The patient received the IM medication at 1:05 PM per the transfer/discharge form. No order could be found for the IM medication, no documentation of the IM on the medication administration record, no behaviors documented justifying the use of the IM beyond the patient being agitated, and no re-evaluation of the patient post medication administration as evidenced by documentation that ambulance left with the patient at 1:15 PM.

The nurse acknowledged the patient's anxiety and provided medication, which was not effective. The nurse administered additional medication but failed to document the order, the specific behaviors for which the medication was administered, nor did she document the effectiveness of the medication and assessment of patient ' s condition at discharge.

Based on review of 1 out of 14 medical record reviews, it was determined that patient #1 was administered medication without a physician's order.

Patient #1 per the transfer/discharge form received Zyprexa 2.5mg IM at 1:05 PM on 4/4/14. Although the patient received the appropriate medication per protocol, the medical record review revealed no order for the medication nor was the administration of the medication written on the medication administration record (MAR) and signed by the nurse. The only indication the patient received the medication was on the transfer/discharge form and a progress note written by the nurse. The nurse failed to meet the regulatory guidelines for the preparation and administration of medications.

Based on review of 1 out of 14 medical records, it was determined that the medical record for patient #1 was incomplete and inaccurate.

Patient #1 was admitted to the hospital for evaluation and adjustment of medications as needed for mental health issues. The patient became upset at discharge and was medicated prior to transfer. Patient #1's medical record revealed a failure of the nurse to document a physician order for medication, failure to document the administration of the medication on the medication administration record, and failed to document the effectiveness of the medication and the assessment of the patient before transfer to the long-term facility.