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Based on interview and record review, the hospital failed to ensure medication for one patient (Patient A) was administered according to the physician's order. Patient A did not receive one dose of Lovenox (blood thinning medication) which has the potential to result in the formation of a blood clot.

Findings:

The clinical record for Patient A was reviewed on 1/19/12 at 10:30 AM. A 12/14/11, physician's order was noted for Lovenox (blood thinning medication) 40 milligrams injection daily, give first dose "now". A review of the Medication Administration Record was conducted. There was no documented evidence the Lovenox was given on 12/14/11, as ordered by the physician.

During an interview with the Director of Nursing (DON), on 1/19/12 at 12:15 PM, she was informed there was no documentation the Lovenox for Patient A was administered on 12/14/11, as ordered by the physician. After reviewing the clinical record for Patient A, she was unable to find documentation the Lovenox was administered on 12/14/11, as ordered by the physician.