HospitalInspections.org

Based on a review of facility policy and medical records (MR), and staff interviews (EMP), it was determined that the facility administered a medication without a physician's order for one of 27 medical records (MR1).

Findings included:

Facility policy "Administration of Drugs" revised January 2009 revealed "...A. Drugs shall be administered to patients only upon the receipt of the order from an authorized provider. ..."

1) Upon entering MR1's room on March 16, 2010, at approximately 9:00AM, a scarred area was observed on the front mid thigh area of the left leg approximately 6 inches long and 2 inches wide with scratch marks.

2) A review of MR1 revealed no treatment orders for the scratch wound. During an interview on March 16, 2010, at approximately 10:37AM, EMP2 was asked if a treatment was being completed on MR1's leg wound. EMP2 revealed "... been putting Silvadene on ... (MR1's) ... thigh every day." When asked if there was an order in MR1 for Silvadene EMP2 revealed after review of physician orders in MR1 "I thought there was an order but I guess not because I can't find it."

3) During interview on March 17, 2010 at approximately 11:30AM, EMP1 confirmed that there was no order for Silvadene in MR1 and revealed "EMP2 knows better than that."