HospitalInspections.org

Based on review of facility policy, review of open and closed medical records, and interviews with staff, the nursing staff failed to reassess the effectiveness of administered PRN (as needed) medications for 4 of 5 sampled patients (#3, #7, #8, #10)

The findings include:

Review of the policy titled, "Medication Administration," with revision date of 01/18, revealed "...Documentation: ....2. Reassess patient and document effect of PRN Stat, Single Dose or NOW medication on the PRN Medication form one hour following administration of medication...."

1. Review of closed medical record on 04/10/2018 revealed a 32 year old female (#3) transferred from another facility after treatment for overdose attempt. Patient was IVC (involuntarily committed) on 03/15/2018 with discharge date of 03/21/2018. Review of the MAR (Medication administration record) dated 03/15/2018 revealed documentation of administration of PRN "Zofran (nausea) 4 mg (milligrams) sublingual (under tongue route) for nausea" at 1000 on 03/17/2018; 1455 on 03/18/2018; 1305 on 03/19/2018 and 0914 on 03/20/2018. Review of "Nurse's Medication Notes" revealed no documentation of effectiveness of medication given on 03/17/2018, 03/18/2018, or 03/19/2018.

Interview on 04/10/2018 at 1000 with RN #1 revealed nurses are taught to document reassessments of effectiveness of medication on back of MAR. "The policy says the nurse should reassess within the hour."

Interview on 04/11/2018 at 1440 with AS #1 revealed there was no documentation of the effectiveness of the medication. Interview confirmed policy was not followed.

2. Review of open medical record on 04/11/2018 revealed a 62 year old male (#8) admitted on 04/05/2018 for suicide precautions and alcohol abuse. Review of the MAR revealed documentation of administration of "Vistaril 50 mg po (by mouth) q (every) 4 hrs (hours) PRN (as needed) anxiety at 0625 on 04/09/2018; 1015 and 2000 on 04/10/2018; and 1000 on 04/11/2018. Further review revealed no documentation of effectiveness of medication.

Interview on 04/11/2018 at 1440 with AS #1 revealed there was no documentation of effectiveness of the medication. Interview confirmed policy was not followed.



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3. Closed medical record review of patient (Pt) # 7, on 04/11/2018, revealed she was a 17-year-old female admitted on 12/02/2017 to the facility's adolescent unit with a diagnosis of major depressive disorder and post-traumatic stress disorder (PTSD). Review revealed Pt #7 was admitted as a result of self-harm actions resulting from witnessing the suicide of her mother when at age nine. Review of the MAR (Medication Administration Record) dated 01/03/2018 through the day of discharge, 01/11/2018, revealed administration of Zyprexa 10 mg orally for agitation on 01/07/2018 at 1005 and 1805. Review of "Nurse's Medication Notes" revealed no documentation of effectiveness of the medication for either administration.

Interview on 04/11/2018 at 1135 with RN #3 revealed nurses were taught to document reassessments of medication effectiveness on the back of the MAR.

Interview on 04/11/2018 at 1440 with AS #1 revealed there was no documentation of the effectiveness for the medication. Interview confirmed the policy was not followed.

Interview on 04/12/2018 at 0830 with AS #2 confirmed there had been no documentation of the effectiveness for the medication Zyprexa. Interview confirmed the policy was not followed.




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4. Medical record review of Patient (Pt) # 10, on 04/10/2018, revealed a 60 year-old female admitted on 04/09/2018 with auditory hallucination and erratic behavior. Pt #10 was admitted to the facility for medications adjustments and to ensure her safety. Review of the MAR (Medication administration record) dated 04/10/2018 revealed documentation of administration of PRN (as needed) "Risperdal 2mg (milligrams) PO (by mouth) for Psychosis" at 1600 on 04/10/2018. Review of "Nurse's Medication Notes" revealed no documentation of effectiveness of medication given on 04/10/2018 at 1600.

Interview on 04/10/2018 at 1000 with RN #1 revealed nurses are taught to document reassessments of effectiveness of medication on back of MAR. "The policy says the nurse should reassess within the hour."

Interview on 04/11/2018 at 1440 with AS #1 revealed there was no documentation of the effectiveness of the medication. Interview confirmed the policy was not followed.

NC00135198
NC00137032