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ASCENSION ST FRANCIS HOSPITAL 3237 S 16TH ST MILWAUKEE, WI 53215 Jan. 22, 2020
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the facility failed to follow their policies and procedure to verify patient understanding of their medications to ensure medication is safely administered in 8 of 10 patients receiving medication (Patient #1, #3, #4, #5, #6, #7, and #8) in a total of 10 medical records reviewed.

Findings include:

Review of policy "Medication Administration" # 79 last approved 10/2019 under II. Medication Safety revealed "person administering medication has the responsibility to assure safety... A. Actions to support safe administration...#11. Provide first dose education to the patient and/or family."

Review of policy "Informed Consent for Medication" # 33 last approved 5/2019 under Procedure B revealed "Medication education offered will include the name of the prescribed drug, dosage, route of administration, benefits and risks to the specific drug therapy. C. "Information and education will be offered prior to the first dose of a new medication...D... When a patient indicates an understanding of the information the nurse will ask the patient and/or guardian to sign the "Informed Consent for Medication" form. Refusal to sign the form after education provided must be documented in the record...G...no psychotropic medication may be given to any patient without the prior medication education offered to the patient."

Review of Patient #1's medical record revealed Patient #1 was admitted through the Emergency Department ED 12/09/2019 for testicular injury, had a scrotal exploration procedure. Patient #1 received IV (intravenous) Ancef 12/09/19, Keflex 500mg po (by mouth) 12/09/2019, Bactrim po 12/09/2019, Maxipime IV 12/10/2019 and Flagyl IV 12/10/19. No documentation of patient education with administration of the first dose of these medications was documented.

Review of Patient #1's medical record revealed Patient #1 was admitted through the ED on 12/11/2020 at 12:48 PM for psychiatric evaluation. Olanzapine 5 mg tablet (psychotropic medication) was given in the ED on 12/11/2019 and Patient #1 was admitted to the Behavioral Health Unit. There is no signed "Informed Consent for Medication" in Patient #1's medical record.

Review of Patient #3's medical record revealed Patient #3 was admitted [DATE] for complaints of worsening depression and suicidal ideation's. Patient #3 received Zoloft 50 mg tablet (psychotropic medication) 11/24/2019. There is no "Informed Consent for Medication" documented.

Review of Patient 4's medical record revealed Patient #4 was admitted [DATE] for a psychiatric evaluation. Patient #4 received Zoloft 100 mg tablet (psychotic medication) 11/11/2019. There is no "Informed Consent for Medication" in Patient #4's medical record.

Review of Patient #5's medical record revealed Patient #5 was admitted [DATE] for anxiety and suicidal ideation's. Patient #5 received Nicoderm patch 12/13/2019, there was no documentation of first dose education given on Nicoderm patch, Trazodone 50 mg tablet (psychotropic medication) 12/13/2019, and Zoloft (psychotropic medication) 12/14/2019. "Informed Consent for Medication" column titled "Medication" listed Haldol, Benadryl, Hydroxyzine and Trazodone. Zoloft was not listed on the Informed Consent and there was no dosage, route of administration, benefits and risks listed for Trazodone.

Review of Patient #6's medical record revealed Patient #6 was admitted [DATE] with auditory hallucinations and suicidal ideation's. Patient #6 received Latuda 40 mg tablet 12/24/19, Olanzapine 20 mg tablet 12/23/19, and Geodon 80 mg capsule 12/23/19 (all psychotropic medications). "Informed Consent For Medication" form listed Benztropine, Lamictal, Olanzapine, Hydroxyzine, Topamax and Geodone under column titled "MEDICATION." dated 12/23/19 at 2 PM. Latuda was not listed on the informed consent. There were no dosages, route of administration, benefits and risks to Olanzapine or Geodone listed.

Review of Patient #7's medical record revealed Patient #7 was admitted through the ED 1/01/2020 with depression suicide ideation and alcohol intoxication. Patient #7 received Latuda 20 mg 1/01/2020 and Zoloft 25 mg tablet 1/02/20, both psychotropic medications. There was no Informed Consent for Medications.

Review of Patient #8's medical record revealed Patient #8 was admitted [DATE] for depression and alcohol intoxication. Patient #8 received a Nicoderm patch, there was no patient education on first dose documented, and Trazodone 50 mg tablet (psychotropic medication) 8/20/19. "Informed Consent For Medication" form listed Haldol, Benadryl, Hydroxyzine, Ativan, Trazedone and Quetiapine. There was no dosage, route of administration, benefits and risks to Trazodone listed.

Review of Patient #9's medical record revealed Patient #9 was admitted [DATE] for lower abdominal pain and lower leg pain, diagnosed with acute renal failure and sigmoid diverticulitis/diverticulosis. Patient #9 received Allopurinol 100 mg tablet 6/23/2019 and Flagyl 500 mg IV 6/23/19. There was no patient education on first dose of Allopurinol or Flagyl documented.

On 1/14/2019 at 4:07 PM during interview with Quality Coordinator (QC) C, QC C stated their first dose education has a drop-down in their electronic documentation system but the education "doesn't always get documented there."

On 1/14/2019 at 4:40 PM during interview with Behavior Health Clinical Manager D, Manger D confirmed there was no education on the first dose of medications documented on these patients. When questioned about the "Informed Consent for Medication" policy, Manager D stated "I need to review this policy again."