HospitalInspections.org

Based on policy and procedure review, patient medical record review, and staff interview, the nursing manager failed to ensure that nursing staff implemented policies related to the completion of medication variance reports in regard to delays in medication administration for one patient (pt. #1); and related to follow up within one hour of the administration of pain medications for 3 of 4 patients.
(pts. #1, #2, and #3)

Findings:
1. Review of the policy and procedure "Medication Variance" (no policy number), with a last approved date by the CNO (chief nursing officer) of 4/12 indicated:
a. on page one under section "II. Definitions: Definitions of Medication Variance:...", it states in section "E." "Wrong time (routine med should be given within plus or minus 1 hour of time ordered)..."
b. on page two under section "III. Procedure:", it reads in section "C." "The person who was involved with or discovered the variance must complete an Event Report describing the variance."

2. at 1:20 PM on 3/13/13, review of the medical record for pt. #1 indicated:
a. a note written at 1041 hours on 2/14/13 by nursing staff reads: "Citalopram (Celexa) noted due for 0900. At 0800 searched for med in pyxis...and tube station; did not find med. Notified satellite pharmacy at 266-2680 at 0809 of need for medication. Notified floor pharmacist at 266-3775 of need for medication at 0846 when med not found on unit. Again notified satellite pharmacy at 0935 of continued need for medication. At 1030, still have not found 0900 scheduled citalopram. Notified floor pharmacist who states, "They are working on it.""

3. interview at 10:00 AM on 3/14/13 with staff member # 55, a registered pharmacist, indicated:
a. the ordered dose of Citalopram/Celexa indicated a 1/2 tab was to be given and the facility has "limited splitting tabs"
b. it was decided that the family could provide this medication from home, but this delayed the administration of the 9 AM dose until 4:39 PM on 2/14/13
c. this delay should have resulted in a variance/event report being completed by the nursing staff with an explanation of the reason for a delay in the time of administration of this medication

4. interview with staff member # 53, the accreditation specialist, at 10:15 AM on 3/14/13 indicated:
a. the "system" has been double checked and there was no variance report completed by nursing staff in regards to the delay in administration of Citalopram/Celexa on 2/14/13 for pt. #1, as should have occurred per policy requirement

5. review of the policy and procedure "Medication Administration: Oral" (no policy number and no documentation of a last approved date) indicated:
a. on page 5 under "Monitoring and Care", it reads: "1. Return within an appropriate time to evaluate patient's response to medications. Rationale: Evaluates drug's therapeutic benefit and helps to detect onset of side effects or allergic reactions..."

6. review of the policy and procedure "Pain Relief" (no policy number and no documentation of a last approved date) indicated:
a. under "Procedure", it reads: "...3. Administer pain-relieving medications as ordered..."
b. under "Monitoring and Care", it reads: "1. Within 1 hour of an intervention (e.g., when the drug used is at its peak effect), ask patient to verbalize how well the pain has been relieved. Have patient rate pain intensity now on a scale of 0 to 10. Rationale: Evaluates effectiveness of pain-relieving interventions in a timely manner after each intervention..."
c. under "Documentation:", it reads: "Character of pain before intervention, therapies used, and patient response..."

7. Review of patient medical records indicated:
a. pt. #1 was given:
A. Tylenol 500 mg at 0944 hours on 2/15/13 with nursing documentation at 0956 hours; 1000 hours; 1001 hours; and 1100 hours with no documentation of a pain score or pain relief noted with any of those notations by nursing staff (first pain doc, was at 1200 hours with a zero, per the Wong-Baker faces chart)
B. Tylenol 325 mg at 2140 hours on 2/15/13 for a headache rated as "7" on a pain scale of 0 to 10 but lacked follow up within one hour of the the medication administration--the next nursing documentation was at 2200 hours and 2300 hours, but lacked any pain score or documentation related to pain relief
C. Ibuprofen 200 mg on 2/17/13 at 1725 hours--the next nursing documentation was at 1800 hours with no pain score documentation--the first documentation of a zero pain level was at 2000 hours
D. Ibuprofen 200 mg at 0319 hours on 2/18/13 for pain at a level of "3" with no follow up documented within 1 hour--nursing made notes at 0400 hours and 0600 hours without scoring the patient's pain level or noting any relief

b. pt. #2 was given:
A. Tylenol 650 mg at 1000 hours on 2/15/13 and lacked follow up after the pain medication administration within one hour of being medicated
B. Hydrocodone (Norco) 5-325 mg at 1917 hours on 2/15/13 with the first documentation of a pain level/response at 2215 hours (greater than one hour post being medicated for pain)

c. pt. #3 was given:
A. 4 mg of Morphine at 0412 hours on 2/11/13 for a pain level of "7" with no documentation of a pain score within one hour of the medication
B. 4 mg of Morphine at 0606 hours on 2/11/13 with no documentation of the pain level at the time of administration and follow up not done until 0759 hours when the patient reported a "6" pain level
C. 4 mg of Morphine at 0757 on 2/11/13 (pain at level of "6") with no follow up noted within 1 hour of the administration
D. 4 mg of Morphine at 1103 hours on 2/11/13 (pain at level of "7") with no follow up noted within 1 hour of the administration
E. 4 mg of Morphine at 1309 hours on 2/11/13 with no pain score noted at the time of administration and the next score greater than 1 hour at 1424 hours with 4 mg Morphine again given for a score of "7" and no follow up after the 1424 dose
F. 4 mg of Morphine at 1756 hours on 2/11/13 with no documentation of the patient's pain level and no follow up within 1 hour of administration (next pain score was at 2027 hours)
G. Tylenol 650 mg on 2/12/13 at 1002 hours for pain at a level of "10" with no follow up within one hour of administration (next entry was at 1242 hours with no documentation of a pain level--at 1300 hours pain was a "4"
H. Tylenol 650 mg on 2/12/13 at 1706 hours for pain at a level of "4" with the next pain score at 2100 hours (pain level "4") and no follow up within one hour of administration

8. at 3:15 PM on 3/14/13, interview with staff member #57, the nurse manager for the medical intensive care unit, indicated:
a. after thorough review of several areas/sections of patient medical records #1, #2, and #3, follow up within one hour after pain medication was administered was not documented as listed in 7. above
b. it is noted that some nursing staff failed also to note a patient's level of pain at the time of administering pain medications, besides failing to follow up within one hour of administration of pain meds