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BELLEVUE HOSPITAL CENTER 462 FIRST AVENUE NEW YORK, NY 10016 Aug. 15, 2016
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on the medical record review, and interview, in two (2) of six (6) medical records reviewed, nursing staff did not ensure that patients received medications as ordered by the physician (Patient #s 4 and 5).

Findings include:

Review of the medication administration record for Patient #4 noted the patient did not receive the following medications that were ordered by the physician and scheduled to be given on 4/2/2016 at 10:00 AM:

Levetiracetam (Anticonvulsant), 750 milligram (mg) Intravenous Piggyback.
Senna (Laxative) 17.2 mg tablet by mouth daily.
Docusate Sodium (Stool Softener) 100 mg via nasogastric tube.
Abacavir Sulfate-Lamivudine (Antiretroviral agents) 600-300 mg, 1 tablet by mouth daily.


On 4/8/2016 at 9:35 PM, documentation on the medication administration record noted that a nurse canceled the above medications and indicated the patient was off the unit. However, the review of the medical record did not indicate that Patient #4 left the unit on 4/2/16.


Similar finding was noted in the medical record for Patient #5 who did not receive the following scheduled medications on 4/2/16 at 10:00 AM:

Heparin (blood thinner) 5,000 Units subcutaneous.
Esomeprazole (used for treatment of gastric ulcers) 40 mg by mouth.
Atenolol (Cardiovascular agent) 100 mg tab via nasogastric tube.
Fenofibrate (Cholesterol lowering medication) 160 mg tab by mouth.
Senna 17.2 mg tab via nasogastric tube daily.
Docusate Sodium 100 mg via nasogastric tube.
Multivitamin 10 milliliter (ml) via nasogastric tube.
Albuterol Sulfate (Bronchodilator) 3 ml via nebulizer mouthpiece.

On 4/8/16, 2016, at 9:35 PM, the documentation in the medication record noted a registered nurse canceled medications for Patient #4 and indicated the patient was off the unit. The review of the patient's record revealed no evidence that the patient was off unit on 4/2/16 at 10:00 AM.


At interview with Staff V, Neurological Intensive Care Unit RN on 08/10/16 at 14:33 PM, the nurse stated that Patients #4 and #5 did not receive their morning medications on 4/2/16 because she and another nurse were abruptly removed from their duties.

During interview with Staff S, Assistant Director of Nursing on 8/15/16 at 3:00 PM, he acknowledged the findings.