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.

UNIVERSITY MEDICAL CENTER OF EL PASO 4815 ALAMEDA AVE EL PASO, TX 79905 Feb. 4, 2020
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on record review the hospital failed to prepare and administer drugs and biological's in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient's care as specified under 482.12(c), and accepted standards of practice.

Findings include:

Hospital policies and procedures for the preparation and administration of all drugs and
biological's must not only comply with all applicable Federal and State laws, but also
must be consistent with accepted standards of practice based on guidelines or
recommendations issued by nationally recognized organizations with expertise in
medication preparation and administration. Examples of such organizations include, but
are not limited to:
o American Society of Health-System Pharmacists
(http://www.ashp.org/default.aspx)
o Infusion Nurses Society (http://www.ins1.org)
o Institute for Safe Medication Practices (www.ismp.org)
o National Coordinating Council for Medication Error Reporting and Prevention
(www.nccmerp.org)
o U.S Pharmacopeia (www.usp.org)

One of the nationally accepted standards are set by the National Coordinating Council for Medication Error Reporting and Prevention and requires orders to include indication for use.

Findings include:

Review of 7 (seven) medical records of patient that received a drug order by the physician as a onetime only, revealed, the physician's order did not include indication for the use of the onetime use drug.