HospitalInspections.org

Based on record review and interview the facility failed to administer drugs in accordance with the order of the practitioner and accepted standards of practice for 1 of 1 (Patient #1) patients.

Findings included:

Patient #1 received an order for Haldol 2.5mg PO (by mouth) Q6HR (every 6 hours) PRN (as needed) for agitation/Aggression. Patient #1 was administered Haldol 2.5 mg on 01/08/25 at 05:34 PM, 01/10/25 at 09:06 AM, 01/12/25 at 06:06 PM, 01/13/25 at 06:50 PM, 01/16/25 at 06:46 AM, 01/25/25 at 06:03 AM, 01/29/25 at 06:28 AM, 01/30/25 at 10:56 AM and 02/25/25 at 08:19 AM. Based on record review there was no documentation to justify the reason the medication was administered and no documentation of the effectiveness of the medication.

Patient #1 received an order for Ativan 1mg PO Q8HR PRN for agitation/Aggression. Patient #1 was administered Ativan 1mg on 03/04/25 at 06:34 AM, 03/05/25 at 07:11 AM, 03/06/25 at 06:43 AM, 03/09/25 at 12:30 PM, and 03/10/25 at 12:45 PM. Based on record review there was no documentation to justify the reason the medication was administered and no documentation of the effectiveness of the medication.

During a record review ending at 12:15 PM on 07/03/25 Personnel #2 verified the above information.

The policy titled Medication Administration last revised 05/02/23 reflected..."B...xiv Monitor the effects of the medication to ensure effective patient response..."