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THEDACARE REGIONAL MED CTR - NEENAH 130 2ND ST NEENAH, WI 54956 Oct. 29, 2018
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, facility staff failed to document the final medication dose administered via patient controlled analgesia [PCA] for 3 of 3 patients receiving PCA administered medications, out of 10 total patients reviewed (Patient #1, Patient #3, Patient #10).

Findings include:

Review of facility policy "Patient Controlled Analgesia - PCA" No. 192 revealed "D. Discontinuing the PCA pump: 1. The RN or LPN who stops the infusion will document the final history. 2. One RN and another licensed person to waste unused PCA medication by following the process outlined in the campus specific Controlled Substance policy."

Review of Patient #1's PCA orders revealed a morphine PCA pump for 3 mg continuous dose and 1 mg interval dose. Review of Patient #1's PCA Settings flowsheet revealed Patient #1's PCA pump history was cleared and documented on 9/15/2017 at 12:28 PM, with a total morphine dose of 8 mg administered since the previous documented history on 9/15/2017 at 8:01 AM. The PCA pump was "stopped" and discontinued on 9/15/2017 at 7:28 PM. There was no documentation of the PCA history or medication administered between 12:28 PM and 7:28 PM.

Review of Patient #3's PCA orders revealed a morphine PCA pump for 2 mg continuous dose and 2 mg interval dose was initiated on 9/21/2017 at 3:01 PM. Per medical record review, Patient #3 expired on [DATE] at 3:15 PM. The PCA pump medication administration history was not documented.

Review of Patient #10's PCA orders revealed a hydromorphone PCA pump for 0.4 mg continuous dose and 0.4 mg interval dose. Per Patient #10's PCA flowsheet, a new bag was started on 9/3/2017 at 4:43 PM. Patient #10 expired on [DATE] at 10:35 PM. The PCA pump history medication administration was not documented between 9/3/2017 at 4:43 PM and 9/4/2017 at 10:35 PM, the time it was discontinued.

During an interview on 10/29/2018 at 1:00 PM, Registered Nurse J stated "we clear out the PCA pumps every 4 hours." When asked if pumps are cleared and doses documented at the time of death or if the PCA is discontinued, J stated "I believe so."

During an interview on 10/29/2018 at 3:15 PM, Registered Nurse H stated "we clear the pump every 4 hours. We take a final history [when the PCA is discontinued] and document that and get rid of the rest of the medication."

During an interview on 10/29/2018 at 2:15 PM, Accreditation Coordinator A stated "I'm not sure" why the doses aren't documented.

During an interview on 10/29/2018 at 3:30 PM, Quality Vice President C stated "the PCA doses can be calculated if we look at the waste logs, but they should be documented [in the medical record]."