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.
|SOUTH BAY HOSPITAL||4016 SUN CITY CENTER BLVD SUN CITY CENTER, FL 33573||Sept. 1, 2011|
|VIOLATION: RN SUPERVISION OF NURSING CARE||Tag No: A0395|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on clinical record review and staff interview it was determined that the Registered Nurse did not ensure patients were assessed prior to administration of medications for allergies for 1 (#1) of 10 sampled patients. This practice does not ensure patient safety and may cause a prolonged hospital stay.
Patient#1's admission assessment dated [DATE] at 8:53 p.m. revealed the patient's allergy list. The medication Lorazepam (Ativan) was listed on the allergy list as causing difficulty in breathing and hives.
A review the Medication Administration Record (MAR) dated for 7/15/11 revealed the patient received Ativan 0.5 milligrams (mg) by mouth at 6:47 a.m. and again at 8:37 p.m.
A review of the nursing documentation for 7/15/11 thru 7/16/11 did not reveal any documentation addressing the needs for administering the Ativan or notifying the physician of the known allergy to the medication.
Interview with the Director of Quality on 9/1/11 at approximately 4:00 p.m. confirmed the findings.