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.

LOYOLA UNIVERSITY MEDICAL CENTER 2160 S 1ST AVENUE MAYWOOD, IL 60153 Aug. 27, 2015
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined, for 2 of 10 clinical records reviewed (Pt. #1 and 7), the hospital failed to ensure medications were administered timely in accordance with physicians' orders.

Findings include:

1. On 8/24/15 at 2:00 PM, hospital policy # MED-001, titled, "Medications - Administration", revised August 2013, was reviewed. The policy required, "F. Standard Medication Administration Times... 3. Non-time critical scheduled medications... a. Daily, weekly, or monthly medications: administer within 2 hours before or after the scheduled time. b. Medications prescribed more frequently than daily... within 1 hour before or after the scheduled time."
2. On 8/26/15 at 2:45 PM, an interview was conducted with the Manager (E #1) of 6 SW (oncology unit). E #1 stated medications scheduled for 2 times a day (BID) are administered at 9 AM and 9 PM; 3 times a day (TID) at 9 AM, 3 PM, and 9 PM; and 4 times a day (QID) at 9 AM, 3 PM, 9 PM, and 3 AM.

3. On 8/24/15 at 1:30 PM, Pt. #1's clinical record was reviewed. Pt. #1 was a [AGE] year old male, admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]. #1's admission to his date of death (7/14/15). For approximately 500 medications received or refused by Pt. #1, some medications were administered late including:

- 6/13/15 - pipercillin (antibiotic), 3.375 grams (g), IVPB (intravenous piggy back), every 6 hours, start at 12:00 PM, was administered at 7:30 PM, greater than 1 hour late. No reason was documented as to why the medication was late.

- 6/18/15 - fat emulsion, 20%, 250 ml, "standard lipid hang time is 8:00 PM," was hung at 10:18 PM, more than 2 hours late. No reason was documented as to why the medication was late.

- 6/21/15 - clindamycin (antiinflammatory), 600 mg, in 5% dextrose, 50 ml IVPB, every 8 hours, was hung at 9:30 AM, more than 9 hours after the previous dose (on 6/20/15 a 11:37 PM). No reason was documented as to why the medication was late.

4. Pt. #7's clinical record was reviewed on 8/26/15 at 2:00 PM. Pt. #7 was a [AGE] year old male, admitted on [DATE], with a diagnosis of [DIAGNOSES REDACTED]. No reason was documented as to why the medication was late.

5. On 8/26/15, between 1:00 PM and 3:00 PM, medication records were reviewed with the Manager of 6 SW (E #1) and an interview was conducted with E #1. E #1 stated Pt. #1 often refused medications when scheduled, but later, requested to take the medication [causing them to be late].