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ROCKLEDGE REGIONAL MEDICAL CENTER
No Description Available
Tag No.: A0404
Based on record review, the facility failed to ensure that drugs in the form of intravenous (IV) infusions of Dilantin were administered in accordance with accepted standards of nursing practice for 1 of 5 sampled patients (#1).
Findings:
A review of the medical record of patient #1 was performed. The patient was admitted to the Emergency Room (ER) on 8/23/10 at 1:52 AM. The chief complaint was stated as, "Pt c/o swelling and heaviness above Lt eye onset this AM. Denies injury." Medication allergies were stated in the Triage Assessment as being none.
The record revealed an infusion site on the right hand. A nurse's note at 2:40 AM indicated that a saline lock was installed on the right hand, 20 gauge, with blood return.
Physician orders at 3:36 A.M. read, "Phenytoin 1 gram IV." A nurse's note at 4:04 AM stated, with respect to "Phenytoin (Dilantin) 1 gram IV . . . Given IVPB (Intra Venous Piggy Back) @ 240 mls/hr (milliliters per hour) per pharmacy. Allergies and 5 rights verified." A nurse's note at 4:30 AM read, "Pt sts (states)... IV is burning. Rate on Dilantin changed from 240/ml/hr to 100 ml/hr." A nurse's note at 4:50 AM read, "Checked on pt to evaluate IV. Pt sleeping in no distress." A nurse's note at 5 a.m. read, "Pt sts ... has to have this IV out. Sts is burning terribly. Hand is slightly swollen. Pt very agitated."
There was no evidence in the medical record of the nurse terminating the infusion and removing the IV catheter, which was reported by the patient as having caused burning. The lack of such action is contrary to standard nursing practice.
A nurse's note at 5:10 AM on 8/23/10 read, "Pt left extremely agitated. Right hand slightly swollen. MD aware. Pt would not stay for discharge vitals."
No Description Available
Tag No.: A0404
Based on record review, the facility failed to ensure that drugs in the form of intravenous (IV) infusions of Dilantin were administered in accordance with accepted standards of nursing practice for 1 of 5 sampled patients (#1).
Findings:
A review of the medical record of patient #1 was performed. The patient was admitted to the Emergency Room (ER) on 8/23/10 at 1:52 AM. The chief complaint was stated as, "Pt c/o swelling and heaviness above Lt eye onset this AM. Denies injury." Medication allergies were stated in the Triage Assessment as being none.
The record revealed an infusion site on the right hand. A nurse's note at 2:40 AM indicated that a saline lock was installed on the right hand, 20 gauge, with blood return.
Physician orders at 3:36 A.M. read, "Phenytoin 1 gram IV." A nurse's note at 4:04 AM stated, with respect to "Phenytoin (Dilantin) 1 gram IV . . . Given IVPB (Intra Venous Piggy Back) @ 240 mls/hr (milliliters per hour) per pharmacy. Allergies and 5 rights verified." A nurse's note at 4:30 AM read, "Pt sts (states)... IV is burning. Rate on Dilantin changed from 240/ml/hr to 100 ml/hr." A nurse's note at 4:50 AM read, "Checked on pt to evaluate IV. Pt sleeping in no distress." A nurse's note at 5 a.m. read, "Pt sts ... has to have this IV out. Sts is burning terribly. Hand is slightly swollen. Pt very agitated."
There was no evidence in the medical record of the nurse terminating the infusion and removing the IV catheter, which was reported by the patient as having caused burning. The lack of such action is contrary to standard nursing practice.
A nurse's note at 5:10 AM on 8/23/10 read, "Pt left extremely agitated. Right hand slightly swollen. MD aware. Pt would not stay for discharge vitals."