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BAPTIST MEDICAL CENTER 111 DALLAS STREET SAN ANTONIO, TX 78205 Oct. 25, 2012
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, there was no documentation available to confirm that nursing staff administered patient #1's vaccine as ordered by physician #1.

Findings included:

Record review on 10/16/12 of patient #1's medical chart revealed a physician's order written by physician #1, dated 04/19/12 at 0400 AM, that included but was not limited to the following: DTaP ([DIAGNOSES REDACTED], Tetanus and Pertussis) IM (Intrmuscular) times 1 now.

Record review of patient #1's medical chart did not reveal documentation of nursing staff administering the ordered vaccine.

Record review of patient #1's History and Physical, dated 04/19/12 at 0345 AM and completed by physician #1, revealed the following: "Patient #1 is a [AGE] year old female with past history of hypertension and anxiety, who presents to the Emergency Department complaining of some low grade fevers and infection of her thumb. She states that her cat bit her on the thumb and the tooth went through and through the flesh. She states that over the past several days, the wound has progressively become more painful and swollen and there is some red streaking starting to go up her arm. She is being admitted for IV antibiotics."

Interview by phone on 10/25/12 at approximately 10:00 AM with the Director of Risk Management revealed that she would review patient#1's chart to determine if there was written documentation of patient #1 receiving the DTaP vaccine. She confirmed the nursing staff should have documented the vaccine as given according to physician #1's order.

Record review of an email from Director of Risk Management, dated 10/25/12 at 6:49 PM confirmed the
administration of the DTaP vaccine was not documented by nursing staff in patient #1's record.