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Based on the review of the Medication Administration Record and interview with the Pharmacist, it was determined that Dilaudid 4 mg by mouth as ordered by the physician every six hours was not dispensed as ordered by the Physician of Patient #5.

The findings included:

The clinical record of Patient #5 (Clinical record #5) was reviewed between the periods of April 29, 2010 until August 3, 2010. Patient #5's diagnoses included an Abdominal Fistula (An Abdominal fistula is an opening from an organ in the body to an opening in the outside of the body.), Protein Malnutrition, Morbid Obesity, history of Deep Vein Thrombus (An abnormal condition in which a clot develops within a blood vessel in the body) and Sleep Apnea (An absence of automatic breathing during sleep). Patient #5 was admitted from Durham Hospital in North Carolina and received Total Parental Nutrition (TPN) (A way to give full nutrition when needed for a long time via a catheter in the vein that drains into the right upper chambers of the heart). Food was initially forbidden due to the abdominal fistula for Patient #5.

After returning from attempted transfer to Randolph Health and Rehab, Patient #5 was ordered Dilaudid 4 mg by mouth every six hours.

On June 13, 2010, the Dilaudid 4 mg by mouth was administered at 01:40 AM, when it was due at midnight. The twelve noon dosage was administered at 2:43 PM, on June 13, 2010. On June 15, 2010, the Dilaudid 4 mg by mouth was administered at 01:56 AM, when it was due at midnight.

Pharmacist #2 stated during interview via telephone on August 23, 2010 at 11:45 AM, that the standard for dispensing medication was to dispense the medication within one hour of the time ordered.