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Based on medical record review and interview, the nurse failed to bathe and/or document baths given for eight days to Patient Identifier (PI # 1), a patient with Closed Head Trauma requiring maximum assistance with bathing. This affected one of two sampled patients requiring maximum assistance with bathing.

Findings Include:

According to the History and Physical dated 10/12/2012, PI # 1 was admitted to the hospital on October 10, 2012 due to declining function at home. PI # 1 requires moderate assistance for bathing.

There is no documentation in the medical record to indicate PI # 1 was given a bath and /or shower on the following dates:
10/11/2012, 10/12/2012, 10/13/2012, 10/14/2012, 10/15/2012, 10/16/2012, 10/17/2012 and 10/22/2012.

During an interview on January 10, 2013 at 11:00 AM, Employee Identifier # 1 confirmed the lack of baths given to PI # 1 and/or lack of documentation regarding baths/showers for the dates documented in the above paragraph.

Based on medical record review and interview, the pharmacist failed to ensure the correct dose of Dantrium was written by the physician for patient Identifier # 2. As a result, PI # 2 received five incorrect doses of oral Dantrium (25 milligrams). This deficient practice affected one of one sampled patients.

Findings Include:

Patient Identifier (PI ) # 2 was admitted to the hospital on 11/29/2012 with a diagnosis of Late affects of Traumatic Brain Injury status post Crash.

A physician's order, dated 12/5/2012 at 10:30 AM, documents Dantrium 25 milligrams (mg.) po (by mouth) qid (four times per day).

On 12/10/2012, a physician's order dated 12/10/2012 at 9:00 PM, reveals decrease Dantrium 12.5 mg. po qid.

A Pharmacist Communication Form, dated 1/11/2012, from the pharmacist Employee Identifier (EI ) # 4 to Patient Identifier # 2's physician reveals, "...We can't make Dantrium 12. 5 mg. po QID b/c (because) it's a capsule - 25 mg." There is no written / documented response from the physician regarding the Dantrium in PI # 2's medical record.

A review of PI # 2's Medication Administration Record reveals no order for Dantrium 12.5 milligrams po QID.

During an interview on January 9, 2013 at 1:50 PM, the pharmacist Employee Identifier (EI) # 4 stated Dantrium is the same medication as Dantrolene. The initial order for Dantrolene 25 milligrams po QID was written by PI # 2's physician on 12/5/2012. On 12/10/2012 an order was written by the physician to decrease Dantrolene to 12.5 mg QID. According to the pharmacist (EI # 4), a communication form was placed in PI # 2's medical record notifying the physician that Dantrium was not available as ordered in a 25 milligram capsule. There was no written/documented response by the physician to the communication from the pharmacist. The pharmacist (EI # 4) stated she failed to follow up with the physician about the Dantrium. The physician order for Dantrium 12.5 milligrams (written 12/11/2012) was never transcribed on PI # 2' MAR because the dose was not correct (Dantrium not available in 12.5 mg dose). Nursing staff continued to administer Dantrium 25 milligrams po QID as ordered on 12/5/2012 and transcribed on PI # 2's Medication Administration Record.

A review of Patient Identifier (PI) # 2's Medication Administration Record (MAR) reveals an order for Dantrolene (Dantrium) 25 milligrams po four times a day. According to the MAR, Dantrolene 25 milligrams was administered three times on 12/12/2012 at 8:00 AM, 12:12 PM and 5:00 PM. Dantrium 25 milligrams po was also administered on 12/13/2012 at 8:45 AM and 12:12 PM. A total of five oral doses of Dantrolene/Dantrium 25 milligrams were incorrectly administered to PI # 2 because:
- the physician wrote an order for Dantrium 12.5 milligrams on 12/10/2012 and Dantrium is not available in a 25 milligram dose;
- the pharmacist failed to follow up with the physician regarding the non-availability of Dantrium 12.5 mg;
- the order for Dantrium 12.5 milligrams was not written on PI # 2's MAR
- the order for Dantrium 25 mg milligrams po qid was not held and/or discontinued on PI # 2's MAR.

During an interview on January 10, 2013 at 10:00 AM, the Chief Nursing Officer/ Employee Identifier (EI #) 1 agreed Patient Identifier (PI) # 2 incorrectly received five doses of Dantrium 25 milligrams.