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SUNDANCE HOSPITAL 7000 US HIGHWAY 287 ARLINGTON, TX 76001 June 11, 2013
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on interview and record review the hospital failed to ensure drugs and/or biologicals were prepared and administered in accordance with orders of the practitioner and accepted standards of practice to meet the needs of patients. Medication Administration documentation and/or Accucheck (blood sugar) results was not completed for 4 of 10 patients (Patient #6, #7, #8 and #9). No start/stop date was transcribed to the MAR (medication administration record) for 1 of 10 patients. (Patient #7).

Findings Included:

1) (Patient #6's) History and Physical dated 06/01/13 reflected, 'Paranoid Schizophrenia..."

The Physician's orders dated 05/31/13 reflected, "Depakote ER (extended release) 500 mg (milligrams) po (by mouth) HS (hour of sleep), Zyprexa 10 mg po HS..."

The MAR dated 06/05/13 reflected no documentation indicating Depakote 500 mg ER po HS was administered at the hour of sleep on 06/05/13.

The physician's orders dated 06/01/13 reflected, "Discontinue Zyprexa, increase Zyprexa 15 mg po HS..."

The MAR dated 06/05/13 reflected no documentation indicating Zyprexa 15 mg po HS was administered at the hour of sleep on 06/05/13.

2) (Patient #7's) History and Physical dated 06/05/13 reflected, "Admitting diagnosis...Major Depressive Disorder and Post-traumatic Stress Disorder...voiced Depression and Suicidal Ideation..."

The physician's orders dated 06/05/13 timed at 09:30 PM reflected, "Prozac 10 mg po every day, Lamictal XR (extended release) 600 mg po every day, Albuterol two puffs inhalation every 6 hours prn (as needed) times dyspnea...ASA (aspirin) 81 mg po every day..."

The physician's orders dated 06/05/13 timed at 21:55 PM reflected, "Lisinopril 10 mg po daily..."

The MAR dated 06/08/13 reflected no documentation indicating ASA 81 mg po every day, Prozac 10 mg po every day, Lamictal XR 600 mg po every day, Lisinopril 10 mg po every day was administered at 09:00 AM.

The MAR reflected no start/stop date for Albuterol two puffs inhalation every 6 hours prn for dyspnea.

3) (Patient #8's) History and Physical dated 06/06/13 reflected, 'Patient states she has been depressed recently as a friend who helps take care of her was recently found dead in her home..."

The physician's orders dated 06/06/13 timed at 10:30 AM reflected, "Depakote ER (extended release) 500 mg po daily for three days."

The MAR reflected no documentation indicating the Depakote ER 500 mg po daily for three days was administered at 09:00 AM on 06/08/13.

4) (Patient #9's) History and Physical dated 06/09/13 reflected, "Major Depressive Disorder...Suicidal Ideation, and Auditory Hallucinations..."

The physician's orders dated 06/07/13 reflected, "Accuchecks QID (four times a day) AC (before meals) and HS..."

The MAR reflected no documentation indicating the accucheck (blood sugar) results were completed on 06/10/13 at 13:00 PM and 17:00 PM.

On 06/11/13 at approximately 02:15 PM Staff #2 verified the above findings.Staff #2 stated the nursing personnel are aware medications and blood sugars are supposed to be documented on the MAR.

The policy entitled, "Medication Administration Record" with an issue date of 11/15/10 reflected, "Medication documentation is recorded on the MAR...transcribe the order to the appropriate section of the MAR...include start/stop dates...the MAR is a legal record of all drugs administered to the patient...."