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NW INDIANA-AMG SPECIALTY HOSPITAL
ADMINISTRATION OF DRUGS
Tag No.: A0405
Based on document review and interview, nursing services failed to document medication administration in one instance (Patient # 4).
Findings include:
1. Review of hospital policy titled: K.11.31 Administration of Medication, Policy Stat ID 17926994, indicated under Procedure, on page 3, C. The Pharmacist will check all new medication orders; D. The healthcare professional administering the medication will review the medical record and verify that there are no contraindications for administering the medication; F. The healthcare professional administering the medication will document medication administered on the MAR (Medication administration record). Last reviewed 4/2025.
2. Review of Patient # 4's MR (Medical Record), reflected the following:
(a). Patient # 4, a 66 year old, admitted to ALTH # 40 (Long Term Acute Care Hospital) on 6/25/2025 from AH # 60 (Acute Care Hospital); with diagnosis(es) of, but not limited to: S.O.B. (Shortness of breath) & respiratory failure. Patient coded on 6/26/2025 at 11:25 am, and expired on 6/26/2025 at 11:56 am.
(b). Order on 6/26/2025 at 10:30 am, by MD # 31 (Doctor of Medicine-MD/Pulmonary) indicated Morphine 2 mg (milligram) IV (Intravenous) Q (every) 4 hrs (hours) as needed.
(c). MAR dated 6/26/2025 lacked documentation entry by N # 20 (RN {Registered Nurse}- Staff Nurse - Agency Nurse) for Morphine administration for am/day shift (7:00 am - 6:59 pm).
3. Review of Pharmacy document (medLogic) for Med-dispense, on 6/26/2025; for pull of Morphine, for patient # 4, indicated - Quantity 1; Morphine Injectable - 2 mg; User: N # 20, Witness: A # 1 (Chief Clinical Officer); for patient # 4; date/time: 6/26/2025 at 10:06 am.
4. In interview on 8/19/2025 at approximately 2:20 pm (via phone) with A # 1, confirmed the following:
(a). Verified Morphine 2 mg IV was given to patient # 4, after pull from the Med-dispense at 10:06 am, and was noted as a new order - on 6/26/2025.
(b). N # 20 did not note entry - initial on MAR for Morphine 2 mg IV given at 10:06 am.