HospitalInspections.org

Based on interviews with patient/complainant, attending emergency nurse, reviews of medical record and facility medication administration policy medication was not administered on the orders of the emergency room practitioner.

Findings:

a. Interview with complainant/interviewee #1 on March 26, 2025 at 1:32pm via telephone who explained she came to the emergency department on January 30, 2024 at 8:32 pm with chief complaints of chest pain and diaphoresis. The patient explained that she was assessed and received a medical screening. It was explained by the provider that the patient would receive medication to relieve pain. The patient said she waited several hours and never received this medication which would relieve her symptoms. The pain eventually subsided on its own without medications. She said she requested to leave the facility after several hours. She was advised not to leave. She was given some of the medications that she was promised earlier for treatment before she left the facility. She signed out against medical advice.

b. Interview interviewee #3, Patient of concern attending emergency room nurse on March 28, 2025 at 6:16 pm who remembered the patient and admitted that she felt bad about this patient. Interviewee #3, RN said she had 4 other patients and she was trying to get to this patient room to give her the medications ordered. But everytime she tried to go to the patient of concerns room a more urgent matter would come up with one of the other 4 patient and she would have to re-direct and respond to one the other 4 patients. She said it was a very busy shift. She finally explained the matter to the charge nurse and asked charge nurse to check on the patient and administer ordered medications.

c. Review of providers orders January 30, 2025 documented patient was to receive medications including Zofran injection 4mg, Morphine 4mg/ml injection, At 9:14pm on January 30, 2025 orders were added to give patient chewable aspirin 3.24mg and Nitroglycerin SL Tablet 0.4mg PO by provider Valerie Knudson,DO. Orders for Lovenox syringe 100 mg and Plavix tablet 300mg was ordered at 10:15pm. Medical record documentation shows the patient receiving Zofran injection via peripheral IV, Aspirin chewable tablet 325mg, Plavix tablet 300mg and Lovenox 100mg. Medications were administered after the patient stated that she wanted to leave the hospital and before she sign out AMA These medications were administer at 1:15am-1:16 am on January 31, 2025.

d. Review of facility Medication Administration Policy Procedure H-142-p last revised in 2024. On page 1 of 4 under procedure section 4 it states "All Medications should be given via the reported route ordered by the practitioner." The patient was ordered by practitioner at 9:14pm on January 30, 2025 to take oral medications chewable aspirin, 3. 24mg, Nitroglycerin sub-lingual tablet, Plavix tablet 300mg, Zofran injection 4mg and Lovenox syringe 100mg.

-The patient was not given oral medications until after 1 am January 31, 2025 after she threatened to leave the emergency room Against medical advice (AMA).