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Based on record review and staff interview it was determined the registered nurse failed to supervise and evaluate nursing care for pain management for 1 (#4) of 10 sampled patients.

Findings include:

Patient #4 was admitted to the facility on 8/27/13 with right renal calculus. Review of admitting orders revealed the physician had entered orders for morphine 2-3 every 2 hours as needed for pain milligrams and for lortab 1 tablet every 4 hours as needed for pain.

Review of the nursing documentation for pain assessments revealed the patient reported pain at 5 on a 0-0 pain scale at 12:58 p.m. on 8/28/13. Review of Medication Administration Record (MAR) revealed no evidence that pain medication had been administered. There was no documentation of any other intervention. The patient's pain level was not assessed again until 3:41 p.m. (3 hours later). It was reported as 4. The nurse administered morphine at that time.

The Education Specialist was present during the record review between 9:30 a.m. and 11:00 a.m. on 8/29/13. She confirmed the above findings. She also obtained the report from the medication dispensing system from 8/28/13. There was no documentation the nurse had removed any pain medication from the machine during the timeframe in question.

Based on record review and staff interview it was determined the facility failed to ensure accurate medication administration for 1 (#1) of 10 sampled patients.

Findings include

Patient #1 presented to the Emergency Department (ED) on 6/20/13 with bleeding from the circumcision site. Review of ED physician orders revealed Morphine 0.1 milligrams per 1 kilogram of body weight intravenously was to be administered.

Review of nursing documentation revealed the patient weighed 5.2 kilograms. The patient should have received 0.5 milligrams of Morphine. Review of documentation by ED nursing and physician revealed 2.5 milligrams of Morphine was administered in error.

The Risk Manager and former ED nurse manager were interviewed regarding the error on 8/28/13 at approximately 3:00 p.m. The nurse manager, who was the ED manager at the time of the error, explained that one nurse had prepared the Morphine in a syringe with a dilution of 1 milligram per 1 cc. The syringe was then given to another nurse to administer. The nurse who administered the medication misunderstood the contents of the syringe. The nurse administered over 1/2 of the contents of the syringe before the nurse who had prepared the Morphine noticed the error being made and told the nurse to stop the administration. The nurse manager stated the practice in the ED is that nurses do not administer medications prepared by other nurses.

Review of the facility's policy "Medication Administration", #002-0023-7300-000-C, revised 6/13, revealed the policy had not been revised to instruct staff regarding a prohibition of administering medications prepared by another nurse. There was no evidence that the staff had been cautioned about the danger of medication errors if this practice was followed.