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Based upon review of 1 of 8 Emergency Department medical records (#2), Emergency Department Policies and Procedures, and interviews, the Registered Nurse failed to: 1) follow Policies and Procedures related to conducting a re-assessment of the response and effectiveness of medications administered to patient #2 while in the Emergency Department, and 2) documented on patient #2 ED record the patient's pupils were equal, round, and reactive to light and accomodation when through interview it was found the pupils were not assessed. Findings:

1) Review of the Emergency Department (ED) Medical Record revealed on 08/15/2011, patient #2 presented to the ED with the chief complaint of a "head pain" after hitting her head on the attic stairs. According to the list of medications ordered by the Nurse Practitioner S14 and ED physician S9, the Registered Nurse (RN) S12 documented Ketorolac Tromethamine (Toradol) 30 mg (milligrams), Ondansetron HCL (Zofran) 4 mg, and Dexamethasone (Decadron) 4 mg were administered Intravenously at 2:00 PM on 08/15/2011. At 3:27 PM, RN S12 documented patient #2 refused Meperidine HCL (Demerol) 25 mg and Ziprasidone Mesylate (Geodon) 20 mg; however, review of the ED record revealed RN S12 failed to document why the patient refused these medications. At 3:54 PM on 08/15/2011, RN S12 documented she administered Ziprasidone Mesylate (Geodon) 20 mg Intramuscular, and at 3:55 PM, administered Tramadol HCL (Ultram) 50 mg by mouth and repeated the Ondansetron HCL (Zofran) 4 mg Intravenously. The patient was then released from the Emergency Department at 3:55 PM, the same time these medications were administered. There failed to be documentation by RN S12 patient #2 was re-assessed after the administration of the Geodon, Ultram and Zofran administered at 3:55 PM on 08/15/11.

On 09/21/11, the policy related to assessing the patient after the administration of medications was requested. Emergency Department Director S4 provided the policy titled "Intramuscular Injection Medication" for review. According to this policy, the RN was to document "Documentation: The following should be noted on the patient's chart/electronic medication administration record: 1. Patient's response to medication; and 4. Evaluate and document outcome of PRN (as needed) medications on PRN Effectiveness Intervention."

Review of patient #2's Emergency Department Record revealed there failed to be documented evidence Registered Nurse S12 documented the patient's response and the effectiveness of the medications administered Intravenously or Intramuscular.

2) Review of patient #2's ED record revealed RN S12 documented "Yes" to the patient's pupils being equal, round and reactive to light and accomodation. Interview with RN S12 on 09/21/11 at 9:30 AM, revealed the patient had sunglasses on and refused to remove them because the light hurt her eyes. When questioned if the patient's pupils were assessed as indicated in the ED record, RN S12 replied "no".

Based upon review of 1 of 8 Emergency Department (ED) Records (#2), and interviews, the Registered Nurse failed to follow standards of practice as evidenced by allowing ED patient #2 to hand to her visitor a prescribed medication tablet in order for the patient to consume the medication after being discharged from the ED. Findings:

Interview with patient #2 on 09/16/11 at 10:50 AM revealed while in the Emergency Department, Registered Nurse (RN) S12 gave her the medication Ultram in a pill form for pain. Patient #2 stated RN S12 gave her water to take the medication; however, she could not take the medication with water and required a "Sprite" which she had in the car. According to the patient, she gave the medication to her husband who then placed the medication in his pocket for later consumption.

Interview with RN S12 on 09/21/11 at 9:30 AM, revealed when asked about the administration of the Ultram, RN S12 responded she did give patient #2 the Ultram to take by mouth; however, the patient stated she could not take the medication with water and required a soda. RN S12 further stated patient #2 then gave the medication to her husband who placed it in his pocket for later consumption. When asked if she would continue to allow patients to take medications ordered by the ED Physician home with them, RN S6 stated "yes".

Interview with ED Nursing Director S4 and ED Nursing Manager S7 on 09/21/11 at 9:55 AM revealed when asked about ED patient's being allowed to take medications home with them, S4 responded "no, this is not a dispensing hospital and that is not allowed".