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Based on interview and record review, the hospital failed to: (a) ensure drugs were administered in accordance with the physician's orders; (b) ensure the hospital's policy requirement for drug administration for pain management was implemented; (c) ensure the nursing personnel provided clarification of drug orders to manage pain, for 1 of 1 sampled patient (Patient 1).

Findings:

1. Patient 1 was admitted to the hospital on 9/01/11, for continuing medical care related to an infection. Treatment modalities ordered by the physician included wound care and pain management.

The physician orders dated 9/01/11 included the following pain medications:
a. Hydrocodone- Acetaminophen 1 tablet every 4 hours as needed for moderate pain.
b. Norco 2 tablets every 4 hours as needed for severe pain.
c. Hydromorphone 0.4 milligrams (mg) intravenously every 1 hour as needed for moderate pain.
d. Hydromorphone 0.6 mg intravenously every 2 hours as needed for moderate pain.
e. Hydromorphone 0.8 mg intravenously every 2 hours as needed for severe pain.
f. Tylenol 650 mg every 4 hours as needed for pain.
g. Percocet 5-325 every 2 hours as needed for severe pain.

On 10/05/11 at 10:40 A.M., Patient 1's medication administration records (MAR) and pain assessment log records were reviewed with registered nurse (RN 2). The following were noted:

Pain log record dated 9/04/11 at 11:00 A.M. - Per nursing documentation, the patient's pain scale level was at 6, which was classified as moderate pain per the hospital's pain assessment policy. The MAR showed the patient received 0.8 mg of Hydromorphone instead of the 0.6 mg per physician's order for moderate pain.

Pain log record dated 9/05/11 at 9:45 P.M. and 9/06/11 at 5:20 A.M. - Per nursing documentation, the patient's pain level was 8, which was classified as severe pain per the hospital's pain assessment policy. The MAR showed the patient was given 0.6 mg of Hydromorphone instead of the 0.8 mg as ordered by the physician for severe pain.

The registered nurse (RN2) confirmed during the interview and joint record review on 10/05/11 at 10:40 A.M. that the pain medications as given above were not consistent with the pain scale management policy and physician orders specific to the drug Hydrocodone.

2. A review of Patient 1's medical record was conducted with registered nurse (RN 2) on 10/05/11 at 10:40 A.M. It was noted during the review of the physician admission orders dated 9/1/11 that the physician had given 7 different orders for pain medications (see above drug orders in finding #1). A review however of the above drug orders showed the lack of accuracy regarding the appropriateness of the dosages to be given. Two dosages for the drug Hydromorphone were written as 0.4 mg and 0.6 mg intravenously for moderate pain. Another pain medication, Hydrocodone with Acetaminophen 1 tablet every 4 hours as needed was also ordered for moderate pain.

The drug Norco 2 tablets every 4 hours as needed was also ordered for severe pain, in addition to the Hydromorphone 0.8 mg intravenously for severe pain. An additional drug, Percocet 5/325 every 2 hours as needed for severe pain was also ordered. There was no indication the 3 concurrent drug orders were clarified with the physician.

The drug Hydromorphone, as transcribed in the MAR was written in error to indicate both the 0.6 mg and 0.8 mg to be given intravenously for severe pain. The physician orders were to give the 0.6 mg for moderate pain and 0.8 mg for severe pain.

There was no nursing documentation to indicate the in-depth re-assessment of the patient's pain management medications by either the nurses or the pharmacist when the conflicting drugs orders were received on 9/01/11.