HospitalInspections.org

Based on interview and record review the hospital failed to ensure 1 of 1 RN (RN #9) notified and/or acquired a physician order to hold scheduled medications for 1 of 1 patient (Patient #3).

Findings included:

The history and physical dated 01/11/12 timed at 14:00 PM reflected, "Chemical Dependency, Bipolar, Chronic Back Pain, Depression, patient treats self with Norco (hydrocodone)...medical medications...ambien (sleeping pills), ativan (antianxiety) and Prazosin...well appearing...HR (heart rate) 97, B/P (blood pressure) 145/83, RR (resting respirations), T (temperature) 98.2...pulses normal, breath sounds normal..."

The physician's orders dated 01/10/12 to 01/15/12 reflected no order to hold Patient #3's scheduled medications.

The multidisciplinary progress notes dated 01/14/12 reflected no documentation justifying the reason Patient #3's scheduled medications for 17:00 PM and 21:00 PM were held.

The Medication Administration Record dated 01/14/12 from 17:00 PM to 21:00 PM reflected the following medications were held by RN #9:

Tegretol 200 mg (milligrams) po (by mouth) bid (two times a day) 21:00 PM dose was held.
Topamax 100 mg po bid 21:00 PM dose was held.
Suboxone 4 mg sl (sublingual) qid (four times a day). The 17:00 PM and 21:00 PM dose was held.
Prozasin 2 mg po hs (hour of sleep) 21:00 PM dose was held.
Valium 2.5 mg po tid (three times a day) 17:00 PM dose was held.
Valium 5 mg po hs dose was held at 21:00 PM.

On 04/11/12 at 10:00 AM RN #9 was interviewed. RN # 9 stated she checked on Patient #3 frequently during the day and evening shift. RN #9 stated Patient #3's scheduled medications for 17:00 PM and 21:00 PM were held due to the patient sleeping. RN #9 stated she did not notify the physician nor document the reason for holding the medications.

The Texas Board of Nursing Standards of Nursing Practice Title 22, Part II, CHAPTER 217, Rule 217.11 reflected, "The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization...(D) accurately and completely report and document...(vi) contacts with other health care team members concerning significant events regarding client's status...(N) notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment..."

The hospital policy entitled, "Medication Administration General Guidelines" with an edit date of 03/11 reflected, "If the nurse renders it necessary to hold medication, the physician must be notified immediately. The nurse will then take direction from the physician on if the medication should be changed, resumed or held. An order will be written at that time..."