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KENDALL REGIONAL MEDICAL CENTER 11750 BIRD RD MIAMI, FL 33175 Feb. 10, 2012
VIOLATION: PHARMACY ADMINISTRATION Tag No: A0491
Based on record review and interview the facility failed to ensure the administration of medication in a timely manner to 1 of 15 sampled patients (#4.)

The findings include:


Record review of sample patient #4 revealed she presented in the emergency department on 11/29/11 with abdominal pain. The record revealed the physician diagnosed the patient with colitis and an infection. Review of the documentation revealed the physician ordered Zosyn(antibiotic) 3.375 grams intravenously on 11/29/11 at 9:50 a.m. The patient was administered the Zosyn( antibiotic) on 11/29/11 at 7:39 p.m. (9 hours and 40 minutes after ordered.)

Interview with the Director of the Pharmacy on 2/9/12 at 10:30 am revealed she is aware of the incident with sample patient #4 ' s medication. The Director of the Pharmacy stated that the emergency room physician ordered Zosyn for the patient and that the medication is in stocked in the AccuDose machine in the pharmacy. The Director of the Pharmacy stated that the nurse in the emergency room should have given the medication in the emergency room or notified the pharmacy to send the medication to the patient ' s room once a room was assigned. The Director stated that the envelope that would have alerted the pharmacy to question whether the dose was given in the emergency department was not in the bin so she thinks the envelope must have been returned to the emergency department by mistake. The Director of the Pharmacy stated that this is the first incident of this type she has been made aware of. The Director of the Pharmacy stated that the pharmacy has added a second courier to avoid wait time and that there have been no complaints to the pharmacy regarding services or wait time.