HospitalInspections.org

Based on medical record review and staff interview, the hospital's nursing staff failed to document administration of medications ordered by the physician in 1 of 10 sampled patient records (Patient #2).

Findings include:

A closed medical record review on 06/06/2012 for patient #2 revealed a 45 year-old male was admitted to the hospital on 11/09/2011 through 01/20/2012 with a diagnosis of "Nontraumatic Brain Injury". Review of the hospital's physician orders dated 11/09/2011 at 1736 revealed "BVI if no void for 8 hours, perform in/out catheterization if volume above 150 milliliters". Further review of the physician orders revealed "Lidocaine (anesthetic) jelly PRN (as needed) with cath" written on 11/15/2011 at 1220 as a verbal physician order by a hospital registered nurse. Review of the patient's Intake and Output records revealed documentation that the patient received an in/out catheterization on the dates of 11/16/2011, 11/17/2011, 11/18/2011, 11/22/2011, 11/23/2011, 11/28/2011, 12/14/2011, and 12/26/2011 (Total of eight (8) days). Documentation review of the hospital's "Omnicell's Transaction by Patient (Medication Dispensing Machines)" revealed that the medication Lidocaine was removed from the machines by the hospital's nursing staff for the patient's use on the dates of 11/16/2011, 11/17/2011, 11/18/2011, 11/21/2011, and 11/22/2011 (Total of five (5) days). The record review revealed no documentation in the patient's medication administration record (MAR) or anywhere in the patient medical record that the patient received the medication Lidocaine as ordered for the in/out catheterizations.

An interview on 06/06/2012 at 1150 with the facility's nursing administration staff revealed that no documentation could be found where the hospital's nursing staff documented the patient receiving "Lidocaine" as ordered PRN for the patient's in/out catheterizations if needed. The interview confirmed that the medication should have been documented to be considered given to the patient. The interview also confirmed the nursing staff did remove the Lidocaine from the drug dispensing machines for patient use.



Reference NC00076846.