HospitalInspections.org

Based on document review and staff interview it was determined nursing services failed to follow their policy for medication administration in one (1) of ten (10) medical records reviewed (patient #1). This failure has the potential to adversely affect all patient care.

Findings include:

1. A review of the medical record for patient #1 revealed a physician order for Prednisone 30 milligrams (mg) on 2/15/18. The patient remained on Prednisone 10 mg from 2/15/18 to 2/17/18. Prednisone 30 mg was started on 2/18/18. The patient was not given the correct dosage of Prednisone for three (3) days.

2. A review of the policy titled "Medication Administration", last reviewed 7/25/17, revealed it stated, in part: "Medication shall be given to patients only upon a physician's order and shall be administered within 1 hour of the prescribing time. Any questions regarding the medication order, dosage, name of drug, the physical appearance of the drug, or possible reaction to other drugs currently being administered should be discussed with the pharmacist or ordering physician."

3. An interview was conducted with the Chief Nursing Officer on 4/24/18. She concurred the patient did not receive the correct dosage of Prednisone as prescribed by the physician on 2/15/18.

4. An interview was conducted with the Director of Pharmacy on 4/24/18. She reviewed the medical record for patient #1 and concurred Prednisone 30 mg was not given to the patient when ordered. She stated Prednisone 30 mg should have started on 2/15/18.

Based on document review and staff interview it was determined the pharmacy staff failed to ensure an ordered medication was dispensed in a timely manner in one (1) of ten (10) medical records reviewed (patient #1). This failure has the potential to adversely affect all patients.

The pharmacy failed to fill the order correctly as written by the physician and the patient received the wrong dosage of medication for three (3) days.

Findings include:

1. A review of the medical record for patient #1 revealed a physician order for Prednisone 30 milligrams (mg) on 2/15/18. The patient remained on Prednisone 10 mg from 2/15/18 to 2/17/18. Prednisone 30 mg was started on 2/18/18.

2. An interview was conducted with the Director of Pharmacy on 4/24/18. She reviewed the medical record for patient #1 and concurred Prednisone 30 mg was not given to the patient when ordered. She stated Prednisone 30 mg should have started on 2/15/18.

3. An interview was conducted with the Chief Nursing Officer on 4/24/18. She concurred the patient did not receive the correct dosage of Prednisone as prescribed by the physician on 2/15/18.