HospitalInspections.org

44559

Based on interview and record review of patient medication charting, the facility failed to adhere to proper medicine administration by giving medicine when it's not medically safe to provide for 1 patient out 10 reviewed (P1 through P10). This deficient practice can likely lead to a patient receiving the same controlled substance (a drug or other substance that the government tightly controls because it may be abused or cause addiction) medication twice, where the effects are compounded (doubled).

The findings are:

A. On 08/12/21 at 10:30 am, a record review of Patient 1's (P1) medication records revealed two separate controlled substance medications given within two hours of each other:

1. P1 was given Lorazepam (Ativan (generic name), a medication used to treat anxiety) at 6 pm on 03/25/21 by the day shift nurse. The handwritten order stated it was for the patient's anxiety.

2. P1 was given the daily scheduled medication for anxiety, Clonazepam (generic name) (medicine used to relieve anxiety, stop seizures and relax tense muscles. The most common side effect is feeling sleepy (tired) during the daytime) at 8 pm on 03/25/21 by the night shift nurse.

B. On 08/12/21 at 10:45 am during an interview, Staff (S)#1 (Chief Nursing Officer) confirmed being the Lorazepam (medication for anxiety) was given to the patient at 6 pm. At the end of shift report (a detailed record of a patient's current medical status written by nurses finishing their shifts and then give to the nurse who is beginning their shift.) The day shift nurse should have explained to the night shift nurse to access the patient before giving the scheduled medication for anxiety at 8 pm, which could have caused the patient to be sleepy (tired) before being discharged from the facility.