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ST MARY'S MEDICAL CENTER 901 45TH ST WEST PALM BEACH, FL 33407 June 5, 2013
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on administrative and clinical record review and staff interview, the facility failed to administer the physician prescribed orders as specified by the standards of nursing practice act for 1 of 10 sampled patients (Patient # 1).

The Florida Nurse Practice Act, Chapter 464, includes the administration of treatments and medications as prescribed.

The findings include:

Review of the clinical record for Patient # 1 discloses the patient was admitted to the facility on [DATE] from the emergency room . The physician made the decision to admit the patient to the hospital at 10:17 AM and wrote admitting orders. The patient finally was transferred to the unit at 5:00 PM. The admitting physician orders included the following: Coumadin 5 mg Sunday, Tuesday and Thursday; Coumadin 2.5 mg Monday, Wednesday and Friday; Renexa 500 mg twice daily; Imdur 30 mg twice daily. Review of the corresponding Medication Administration Record (MAR) reveals the patient did not receive the evening dose of the Renexa and Imdur on 4/20/2013. Further review of the MAR revealed the patient did not receive the Renexa until 4/22/2013 at 11:20 PM (3 .5 days after admission). On Monday, 4/22/2013 at 6:15 PM, the nurse administered Coumadin 5 mg and Coumadin 2.5 mg. The patient was prescribed to receive Coumadin 2.5 mg on Monday. There is no additional order prescribing the Coumadin 5 mg which was administered on Monday at 6:15 PM.
Furthermore, it was determined that the Renexa 500 mg was not in the standard formulary hospital supply of medication. However, there is no apparent follow up to ensure the patient received the prescribed medication or an acceptable substitute is provided.

An interview was conducted on 6/4/2013 in the morning with the Risk Manager who stated that the facility's policy for non-formulary medication is the pharmacist will contact the physician for an acceptable substitute. If there is no substitute or if the prescribed medication remains as a requested medication, then the nurse will contact the family to possibly bring in the patient's home supply. Once the home supply is obtained, the medication is taken to the pharmacist for them to label for hospital usage.

An interview was conducted with the Pharmacy Director on 6/4/2013 at 3:50 PM who stated once the pharmacist is faxed the physician orders, he/she performs a medication profile and upon determining medication is not on the hospital formulary an acceptable substitute is provided or the physician is contacted for clarification orders. If the requested medication remains an active order to continue, then a sister hospital is contacted for a temporary supply. He further reported the turnaround time is relatively short and usually obtained within hours versus days. He initially reported the medication (Renexa) is formulary and available. Upon further review, the medication is currently available but at the time of the incident, the medication was not formulary and was not available.

An interview was conducted on 6/5/2013 in the morning with the Nurse Manager who upon review of the patient's clinical record confirmed the above. She stated the nurse should have contacted the patient's family about bringing in his medication, but confirmed the clinical record does not verify this occurred. Additionally, she was uncertain why the patient did not receive some of his bedtime medication, but suspected it was due to the pharmacy not releasing the medication. Furthermore, she was apparently unaware of the Coumadin error. Upon further review of the clinical record, she confirmed there is no corresponding physician order prescribing the patient was to receive the additional Coumadin 5 mg along with the 2.5 mg dose the patient is scheduled to receive.