The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ORLANDO HEALTH 52 W UNDERWOOD ST ORLANDO, FL 32806 June 30, 2016
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, record review and a review of facility documentation, the facility failed to ensure that drugs were administered in accordance with approved policies and procedures for 1 of 10 sampled patients (#1).

Findings:

Patient #1's "ED (Emergency Department) Adult Trauma Flowsheet" indicated that the patient arrived in the emergency room at 9:55 PM on 5/12/16.

Topiramate had been ordered on [DATE] at 1:27 AM specifically as: "Topiramate (same as Topamax) give 200 MG (milligrams) PO (by mouth) 2 times a day." The record revealed that it had been given on 5/13/16 only at 2:02 AM. There was no evidence that a second administration had taken place. "Topamax is used to prevent seizures in adults and children and to prevent migraine headaches." (drugs.com).

A review of facility policy "Medication Scheduling" revealed that two-times-a day medications should be given at 9 AM and 9 PM and that "Routine medication orders are administered within 120 minutes after receipt of the order." The record revealed that a dose was given at South Seminole Hospital, after a 9:15 PM transfer, at 12:20 AM on 5/14/16. This was beyond the accepted time frame.

Ativan had been ordered on [DATE] at 1:27 AM specifically as: "Lorazepam oral (same as Ativan) give 2 MG PO 3 times per day." The record revealed that it had been given on 5/13/16 at the following times as part of a normal schedule: 10:46 AM and 3 PM. There was no evidence that the third administration had been given. "Lorazepam is used to treat anxiety." (mayoclinic.org).

A review of facility policy "Medication Scheduling" revealed that three-times-a day medications should be given at 9 AM, 3 PM and 9 PM and that "Routine medication orders are administered within 120 minutes after receipt of the order." The record revealed that a dose was given at South Seminole Hospital, after a transfer, at 12:20 AM on 5/14/16. This was beyond the accepted time frame. Thus, the facility was not in compliance with the policy.

During an interview of the Risk Manager at approximately 4:15 PM on 6/30/16, she confirmed the findings.