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Based on the review of medical records, it was determined that orders for medications were not written with clear direction for the administration of the medication according to accepted standards of practice. Ten medical records were reviewed for patients who received surgical services (Record #s T3, L3, L4, S1, S2, S3, S4, S5, S6, and S7 ). The medical records contained the preprinted forms, "Postoperative Anesthesia Orders Femoral Block (T3, S3, S4, and S7)" and "General Admission Post Anesthesia Routine Orders (L3)," which were for care following surgery. Five of 10 records reviewed (Records # T3, L3, S3, S4, and S7) contained medication orders that lacked clear direction for administration of the medications. The medication orders failed to identify how the medications were to be used for pain relief, including the order of priority or whether the medications were to be administered one at a time to the maximum dose or concurrently.

Findings are:

An interview of a staff member N1 from the Oregon Board of Nursing on September 18, 2006 at 1400 hours determined that physician order sheets should be designed and implemented to avoid requiring a nurse to make a judgement as to which medication (or medications) to administer from a menu of medications. The orders should rank the medications as to which medication should be given first, second, etc. and the orders should specify a maximum dose for each medication before administering another medication. These decisions are beyond the scope of practice of the Registered Nurse, not in keeping with "prudent, safe, nursing practice standards," and border on prescriptive responsibilities.

The facility's "Postoperative Anesthesia Orders Femoral Block" form listed 2 non-steroidal anti-inflammatory medications: Celebrex 400 mg PO (oral) loading dose, then 200 mg PO twice daily and Toradol 30 mg IV every 6 hours X (times) 48 hours if Creatinine is less than 1.2. Hold toradol if Creatinine is 1.2 or greater; and 3 medications for break-through pain: Dilaudid 1 to 4 mg IV every 4 to 6 hours, or Percocet 1 to 2 tablets PO every 6 hours or Morphine 2 to 5 mg IV every 4 hours.

Record # T3 - This record contained a 5/5/2011 "Postoperative Anesthesia Orders Femoral Block" form on which additional medications for pain were written Vicodin 7.5/325 1 or 2 tablets PO every 6 hours. There was a checkmark in each of the two boxes preceding the Dilaudid and Percocet orders. The medication orders failed to identify how the medications were to be used for pain relief, including the order of priority of the 3 pain medications, or whether the medications were to be administered one at a time to the maximum dose or concurrently.

Record # L3 - This record contained 12/10/2010, "General Admission Post Anesthesia Routine Orders." This form, under the heading "4. Pain management" had a box on which an "X" was written on the form followed by "Fentanyl 25 mg IV q 5 min prn pain." A box preceding "Morphine 1 - 4 mg IV PRN, may repeat up to 10 mg." also contained an "X."

Record # S3 - This record contained a 3/10/2011 "Postoperative Anesthesia Orders Femoral Block" form on which there was a checkmark in each of the two boxes preceding the Dilaudid and Percocet orders. The medication orders failed to identify how the medications were to be used for pain relief, including the order of priority of the 3 pain medications, or whether the medications were to be administered one at a time to the maximum dose or concurrently.

Record # S4 - This record contained a 6/1/2011 "Postoperative Anesthesia Orders Femoral Block" form which had the words "Femoral Block" crossed out and the words "Acute Pain Management" written in. There was a checkmark in each of the two boxes preceding the Dilaudid and Morphine orders. Additionally hand written on the form was a checkbox that had a checkmark and "Oxycodone 5 - 10 mg PO q (every) 4 hrs (hours) prn pain" written in. The medication orders failed to identify how the medications were to be used for pain relief, including the order of priority of the 3 pain medications, or whether the medications were to be administered one at a time to the maximum dose or concurrently.

Record # S7 - This record contained a 6/1/2011 "Postoperative Anesthesia Orders Femoral Block" form. There was a checkmark in each of the three boxes preceding the Dilaudid, Percocet, and Morphine orders. As above, there was no indication as to the order which these medications should be given.