HospitalInspections.org

Based on observation, facility document review, medical records review, and interviews, it was determined that the facility failed follow hospital policy/procedure related to administration and documentation of medications prescribed for the patients.

Findings were:

Facility policy #MM-01 titled "MEDICATIONS" stated in part, "#4 Documentation
All medications shall be documented on the patient's Medication Administration Record (MAR) immediately after administration.
RN/LVN/LPN
" Documents administration of medication by recording the time of administration in the corresponding column of the proper drug column. If the medication is administered by injection, records the site of administration in the integrated progress notes. Draws a single line through the time indicated to signify that the medicine has actually been given, and initials. Signs name, title, and initials at the bottom of the MAR.
" If a dose of scheduled medication is withheld or not given, circles the hour of administration for the medication dose in question and initials next to circled time. Records a full explanation in the integrated progress notes and /or MAR. Physician must be notified, and documentation entered into the pink progress notes of MD notification. (Medication variance must be completed and placed in bin to be processed.


Review of 8 (eight) patient medical records of former patients revealed the following: Patient Medication Administration Records (MAR) variances were noted on 4 of 8 medical records.

" Patient # 1 Admitted 09/28/16 - Discharged 10/18/16
10/12/16 0630 Levothyroxine 75 mcg oral daily, MAR was not initialed that med was given
10/18/16 0630 Levothyroxine 75 mcg oral daily, MAR initial circled, stated, "Out of Stock"

" Patient # 4 Admitted 09/15/16 - Discharged 09/22/16
09/19/16 2100 Melatonin 9 mg oral at Bedtime "not given - out of stock"

" Patient # 5Admitted 09/08/16 - Discharged 9/14/16
09/13/16 2100 Namenda 5 mg oral at Bedtime Medication Administration Record (MAR) was
not initial by the nurse that the medication was given.
09/13/16 2100 Olanzapine 5 mg oral at Bedtime MAR not initialed by the nurse.

" Patient # 9 Admitted 09/20/16 - Discharged 10/12/16
10/10/16 2100 Atorvastin (Lipitor) 20 mg oral at Bedtime- MAR not initialed
2100 Depakote ER 1250 oral at Bedtime - MAR not initialed
2100 Senokot 2 tabs 8.6 mg oral at Bedtime, MAR not initialed
2100 Olanzapine (Zyprexa) 5 mg oral at - MAR not initialed
2100 Namenda 10 mg oral at Bedtime
2100 Docusate Sodium (Colace) Twice a day for constipation, MAR not initialed

10/11/16 2100 Atorvastin (Lipitor) 20 mg oral at Bedtime MAR not initialed
2100 Depakote ER 1250 oral at Bedtime MAR not initialed
2100 Senokot 2 tabs 8.6 mg oral at Bedtime, MAR not initialed
2100 Olanzapine (Zyprexa) 5 mg at Bedtime, MAR not initialed

The above findings were confirmed with the Director of Nursing on the afternoon of 2/13/2017.