HospitalInspections.org

Based on medical record review, facility document review, and staff interview it was determined that medications were not administered as ordered for 2 out of 4 patients sampled (Patients #3, and 4). Findings include:

Facility policy titled Medication Administration Record and Medication Administration stated, " ...Upon administration of the medications, the nurse will document in the MAR [Medication Administration Record] at assigned time slots ... All administered, refused, or omitted medication will be recorded in the patient's MAR ..."

Medical record review for Patient #3 revealed:

Orders placed on 6/13/23 for Metformin 1000mg by mouth twice a day before meals.

Medication Administration record shows no evidence of this medication being given as ordered on 6/21/23.

This finding was confirmed with Employee #1 on 6/29/23 at 11:39am.


Medical record review for Patient #4 revealed:

Orders placed on 5/20/23 for Fluocinolone 0.01% otic oil. Administer 3 drops into each ear every other day.

Medication Administration record for Patient #4 shows no evidence of this medication being given as ordered on 5/29/23 and 5/31/2023.

This finding was confirmed with Employee #4 on 6/29/23 at 13:20 pm.