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.

CLEVELAND CLINIC 9500 EUCLID AVENUE CLEVELAND, OH 44195 March 15, 2018
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on medical record review, policy and report review and interview, the facility failed to ensure medications administered to one patient (Patient #1) of ten medical records reviewed were documented in the medical record. This had the potential to affect all of the facility's 1144 active patients.

Findings include:

The facility's Medication Administration Protocol was reviewed. The policy stated to document at the time of medication administration.

Review of a report listing medications dispensed from the facility's Pyxis system for Patient #1 revealed Staff B, Registered Nurse, removed 2 mg of Morphine on 03/09/18 at 2:44 PM and 2 mg of Morphine at 6:24 PM.

On 03/15/18 at 1:47 PM, Staff B was interviewed. Staff B reported she administered two doses of Morphine to Patient #1 on 03/09/18 and omitted documenting the first dose she administered.

On 03/15/18 at 12:47 PM, Staff F, Director of Medication Safety Services, was interviewed. Staff F confirmed the electronic medical record lacked documentation of the administration of the 2:44 PM dose of Morphine.