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Based on review of professional literature, record review, and staff interview, the Hospital failed to assess and document the effectiveness of medications given to patients on an as needed (prn) basis for 12 of 15 active patient (Patients #1, #2, #4, #5, #6, #7, #8, #9, #10, #12, #13, and #15) and 1 of 5 closed patient (Patient #16) records reviewed. Failure to evaluate the patients' responses to prn medications limited the nursing staff's ability to assess whether the medication achieved the desired effect or if the patients experienced any side effects or adverse reactions from the medication.

Findings include:

Berman and Snyder, "Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice," 9th ed., Pearson Education, Inc., New Jersey, page 862-870, states, ". . . Process of Administering Medications: When administering any drug, regardless of the route of administration, the nurse must do the following: . . . 6. Evaluate the client's response to the drug. . . . In all nursing activities, nurses need to be aware of the medications that a client is taking and record their effectiveness as assessed by the client and the nurse on the client's chart. . . . Skill 35-1 Administering Oral Medications: . . . Evaluation: Return to the client when the medication is expected to take effect (usually 30 minutes) to evaluate the effects of the medication on the client. . . ."

- Review of Patient #1's active medical record occurred on 10/07/15 and identified the Hospital admitted the patient with acute pancreatitis. The record indicated the patient used prn medications for pain and sleep.

Patient #1's medication administration record (MAR) showed the following administration times for the prn medication:
*Dilaudid 1 milligram (mg) intravenous (IV) every two hours prn
10/01/15 - 3:00 a.m.
10/02/15 - 8:11 a.m., 12:55 p.m., 6:31 p.m., and 9:20 p.m.
10/03/15 - 3:04 a.m., 9:51 a.m., 6:23 p.m., and 10:26 p.m.
10/04/15 - 4:15 a.m. and 7:34 p.m.
10/05/15 - 12:12 p.m. and 8:43 p.m.
10/06/15 - 4:16 a.m.
10/07/15 - 12:46 a.m. and 9:44 a.m.
*Hydrocodone/Acetaminophen 5/325 mg one tab by mouth (PO) every four hours prn
10/01/15 - 8:17 a.m., 5:14 p.m., and 8:44 p.m.
10/03/15 - 2:54 p.m.
10/04/15 - 10:05 a.m., 3:17 p.m., and 10:22 p.m.
10/05/15 - 8:35 a.m. and 6:05 p.m.
10/06/15 - 8:29 a.m., 4:51 p.m., and 9:41 p.m.
10/07/15 - 5:35 a.m. and 8:52 a.m.
*Ambien 5 mg PO at 9:00 p.m. prn
10/01/15 - 8:44 p.m.
10/02/15 - 9:20 p.m.
10/05/15 - 8:44 p.m.
10/07/15 - 12:48 a.m.

Review of Patient #1's record failed to include evidence nursing staff assessed and documented the effectiveness or the patient's response to the prn medication.

- Review of Patient #2's active medical record occurred on 10/07/15 and identified the Hospital admitted the patient for wound care. The record indicated the patient used prn medications for pain and bowel care.

Patient #2's MAR showed the following administration times for the prn medication:
*Oxycodone immediate release (IR) 10 mg PO every four hours prn
10/01/15 - 10:02 p.m.
10/02/15 - 9:59 p.m.
10/05/15 - 8:19 p.m.
*Colace 100 mg PO two times a day prn
10/04/15 - 8:29 a.m.
*Bisacodyl 10 mg rectal suppository every day prn
10/04/15 - 12:49 p.m.
*Senna Lax 17.2 mg PO two times a day prn
10/05/15 - 6:38 p.m.

Review of Patient #2's record failed to include evidence nursing staff assessed and documented the effectiveness or the patient's response to the prn medication.

- Review of Patient #4's active medical record occurred on 10/06/15 and identified the Hospital admitted the patient with a foot ulcer. The record indicated the patient used prn medications for pain and nausea.

Patient #4's MAR showed the following administration times for the prn medication:
*Oxycodone/Acetaminophen 5/325 mg two tabs PO every four hours prn
10/02/15 - 7:44 a.m. and 10:56 p.m.
10/03/15 - 11:15 p.m.
10/04/15 - 11:33 p.m.
*Acetaminophen 650 mg PO every four hours prn
10/05/15 - 10:59 p.m.
10/06/15 - 10:34 p.m.
*Zofran 4 mg IV every four hours prn
10/06/15 - 2:30 p.m., response documented at 6:00 p.m.

Review of Patient #4's record failed to include evidence nursing staff assessed and documented the effectiveness or the patient's response to the prn medication and/or in a timely manner.

- Review of Patient #5's active medical record occurred on 10/06/15 and identified the Hospital admitted the patient with acute respiratory failure. The record indicated the patient used prn medications for anxiety, restlessness, and nausea.

Patient #5's MAR showed the following administration times for the prn medication:
*Haldol 2 mg per gastric tube (GT) every four hours prn
10/01/15 - 12:25 a.m. and 11:17 p.m.
10/03/15 - 9:51 a.m.
10/04/15 - 10:44 a.m., 3:09 p.m., and 11:49 p.m.
10/05/15 - 6:49 a.m.
10/06/15 - 12:02 a.m., 2:36 p.m., and 10:05 p.m.
*Lorazepam 1 mg PO every six hours prn
10/01/15 - 3:09 p.m.
10/02/15 - 12:19 a.m.
10/03/15 - 12:23 a.m. and 12:24 p.m.
10/04/15 - 12:06 a.m.
10/05/15 - 11:42 a.m.
10/06/15 - 10:19 a.m. and 10:35 p.m.
*Zofran 8 mg intravenous push (IVP) every six hours prn
10/02/15 - 11:00 a.m. and 6:15 p.m.
10/03/15 - 12:24 a.m., 8:23 a.m., and 6:18 p.m.
10/05/15 - 11:34 a.m.
*Metoclopramide 5 mg PO every six hours prn
10/02/15 - 2:42 p.m.

Review of Patient #5's record failed to include evidence nursing staff assessed and documented the effectiveness or the patient's response to the prn medication.


15707

- Patient #10's active medical record, reviewed on all days of survey, identified diagnoses including osteomyelitis (infection of the bone) and plural effusion (fluid in the lungs). Review of the patient's October 2015 MAR identified Patient #10 received the following PRN medications with no response documented:

Oxycodone (an opioid analgesic) APAP (acetaminophen) 5/325 mg - two tablets orally:
10/01/15 at 9:59 a.m.; 3:15 p.m.; and 8:14 p.m.
10/02/15 at 8:28 a.m.; 2:45 p.m.; and 8:04 p.m.
10/03/15 at 10:12 p.m.
10/05/15 at 9:55 p.m.
10/06/15 at 4:22 p.m. and 8:54 p.m.
10/07/15 at 9:32 a.m. and 1:38 p.m.

Lorazepam (an antianxiety) 1 mg orally:
10/01/15 at 9:59 a.m.; 3:15 p.m.; and 8:14 p.m.
10/02/15 at 8:28 a.m.; 3:52 p.m.; and 8:20 p.m.
10/03/15 at 10:12 p.m.
10/04/15 at 9:33 p.m.
10/05/15 at 9:55 p.m.
10/06/15 at 12:25 a.m.; 4:22 p.m.; and 9:27 p.m.
10/07/15 at 9:32 a.m. and 1:36 p.m.

Morphine (an opioid analgesic) 2 mg intravenously:
10/01/15 at 1:18 p.m.; 5:40 p.m.; and 9:57 p.m.
10/02/15 at 11:12 a.m.; and 10:24 p.m.
10/03/15 at 8:23 p.m.
10/06/15 at 12:20 am.; 1:38 p.m.; and 6:57 p.m.

- Patient #15's active medical record, reviewed on October 5-6, 2015, identified diagnoses including osteomyelitis of the vertebra and insomnia. Review of the patient's October 2015 MAR identified Patient #15 received the following PRN medications with no response documented:

Oxycodone APAP 5/325 - two tablets orally:
10/01/15 at 2:01 a.m.; 5:05 a.m.; 2:18 p.m.; and 8:34 p.m.
10/02/15 at 12:02 a.m.; 7:01 a.m.; 11:29 a.m.; 5:27 p.m.; and 10:03 p.m.
10/03/15 at 2:25 a.m.; 6:37 a.m.; 10:43 a.m.; 5:09 p.m.; and 9:03 p.m.
10/04/15 at 2:13 a.m.; 5:27 a.m.; 9:28 a.m.; 5:21 p.m.; and 9:34 p.m.
10/05/15 at 6:24 a.m.; 12:08 p.m.; and 9:35 p.m.
10/06/15 at 8:23 a.m. and 11:52 p.m.
10/07/15 at 6:38 a.m.; 10:38 a.m., and 2:37 p.m.

Melatonin (to aid sleep) 3 mg orally:
10/03/15 at 9:04 p.m.

- Patient #8's active medical record, reviewed on all days of survey, identified diagnoses including septic thrombophlebitis (inflammation of a blood vessel) and bacteremia (infection in the blood stream). Review of the patient's October 2015 MAR identified Patient #8 received the following PRN medications with no response documented:

Oxycodone IR (immediate release) 5 mg - two tablets
10/03/15 at 8:30 a.m. and 9:41 p.m.
10/04/15 at 10:47 p.m.
10/05/15 at 4:24 p.m.
10/07/15 at 8:25 a.m.

- Patient #6's active medical record, reviewed on all days of survey, identified diagnoses including chronic respiratory failure and rheumatoid arthritis. Review of the patient's October 2015 MAR identified Patient #6 received the following PRN medications with no response documented:

Oxycodone IR 5 mg orally:
10/01/15 at 4:24 a.m. and 6:31 p.m.
10/02/15 at 8:28 a.m. and 2:40 p.m.
10/03/15 at 8:28 a.m. and 2:40 p.m.
10/04/15 at 9:25 a.m. and 4:07 p.m.
10/05/15 at 5:01 a.m.
10/06/15 at 10:54 p.m.
10/07/15 at 7:25 a.m. and 1:06 p.m.

Acetaminophen 650 mg orally:
10/01/15 at 4:24 a.m.
10/03/15 at 8:09 a.m.
10/03/15 at 1:53 p.m.

Ambien (to aid sleep) 5 mg orally:
10/01/15 at 10:35 p.m.

Xanax (an antianxiety) 0.25 mg orally:
10/02/15 at 4:45 p.m.
10/03/15 at 9:37 a.m.

- Patient #12's active medical record, reviewed on October 5-6, 2015, identified diagnoses including acute pancreatitis (inflammation of the pancreas) and anxiety. Review of the patient's October 2015 MAR identified Patient #12 received the following PRN medications with no response documented:

Oxycodone IR 5 mg orally:
10/01/15 at 8:40 a.m. and 7:47 p.m.
10/02/15 at 10:29 p.m.
10/07/15 at 6:39 a.m. and 11:09 a.m.

Zophran (to treat nausea) 4 mg intravenously:
10/01/15 at 12:05 p.m.

Acetaminophen 650 mg orally:
10/03/15 at 9:51 p.m.
10/04/15 at 8:48 p.m.

- Patient #7's active medical record, reviewed on all days of survey, identified diagnoses including lumbar discitis (inflammation of the spine) and osteomyelitis. Review of the patient's October 2015 MAR identified Patient #7 received the following PRN medications with no response documented:

Oxycodone IR 7.5 mg orally:
10/01/15 at 3:36 a.m. and 11:59 a.m.
10/02/15 at 8:26 a.m.
10/03/15 at 4:33 a.m. and 11:46 p.m.
10/04/15 at 11:22 a.m. and 11:58 p.m.

Benadryl (for itching) 50 mg orally:
10/03/15 at 5:17 p.m.

Acetaminophen 650 mg orally:
10/04/15 at 11:22 a.m.

- Patient 13's active medical record, reviewed on October 5-6, 2015, identified diagnoses including acute respiratory failure with hypoxia (low oxygen level). Review of the patient's October 2015 MAR identified Patient #13 received the following PRN medications with no response documented:

Oxycodone IR 5 mg orally:
10/01/15 at 9:21 p.m.
10/02/15 at 8:18 p.m.
10/04/15 at 1:07 a.m.

Haldol (an antipsychotic) 2 mg intravenously:
10/01/15 at 5:51 p.m.

- Patient #9's active medical record, reviewed on all days of survey, identified diagnoses including cholecystoscopy (insertion of a tube in the gallbladder) with complications, bowel perforation, bowel fistula, and dementia. Review of the patient's October 2015 MAR identified Patient #9 received the following PRN medications with no response documented:

Acetaminophen 650 mg orally:
10/03/15 at 11:59 a.m.
10/07/15 at 4:38 a.m. and 2:35 p.m.

Benadryl 25 mg orally:
10/05/15 at 8:56 p.m.

- Review of Patient #16's closed medical record occurred on 10/07/15 and identified the Hospital admitted the patient with acute respiratory failure. The record indicated the patient used prn medications for agitation, anxiety, and pain.

Patient #16's MAR showed the following administration times for the prn medication:
*Haldol 5 mg IVP every six hours prn
08/21/15 - 10:26 p.m.
08/22/15 - 5:35 a.m., 9:30 a.m., 1:30 p.m., and 5:36 p.m.
08/23/15 - 7:49 a.m. and 2:25 p.m.
08/24/15 - 12:09 a.m., 4:26 a.m., and 9:29 p.m.
08/25/15 - 6:05 a.m. and 11:58 p.m., response documented on 08/26/15 at 1:58 a.m.
08/26/15 - 9:32 a.m. and 4:19 p.m.
08/27/15 - 4:37 a.m., response documented at 6:41 a.m.
09/02/15 - 1:15 a.m.
*Lorazepam 0.5 mg IVP prn
08/26/15 - 1:17 p.m. and 1:24 p.m.

Review of Patient #16's record failed to include evidence nursing staff assessed and documented the effectiveness or the patient's response to the prn medication and/or in a timely manner.

During an interview on the morning of 10/08/15, a quality assurance staff member (#1) stated the hospital switched to an electronic medical record in June and this system does not prompt staff to chart PRN medication responses. The staff member (#1) stated the Hospital failed to utilize a policy regarding prn medication administration.