HospitalInspections.org

Based on documentation review it was determined the Hospital failed to ensure drugs and biologicals were administered in accordance with orders in one of one applicable patient record reviewed.

Findings included:


1.) Review of Physician Orders, dated 11/2/09 at 9:48 AM indicated IV Vancomycin was to be administered and the dose was dependent on the Vancomycin level. If the level was less than 15, 1 gram (Gm) was to be administered and if the level was 15 or greater but less than 20, 500 mg were to be administered.

Review of laboratory blood test results, dated 11/2/09 indicated Vancomycin level was 9.8.

Review of medication administration records and Dialysis Records that include documentation of medication administration dialysis did not evidence that specific dose of IV Vancomycin ordered on 11/2/09 was administered.

2.) Hospital policies and procedures related to the administration of medications indicated that the time of administration must be documented.

Review of the Patient's Acute Hemodialysis Treatment Records including documentation for the administration of 500mg IV Vancomycin dated 11/4/09, 11/6/09, 11/9/0, 11/11/09, 11/13/09 and 80 mg Gentamycin on 11/16/09, 11/18/09 and 11/18/09,11/20/09 indicated the time of administration was not documented.