HospitalInspections.org

Based on record review and interview, the hospital failed to ensure medications were administered safely for one (Patient #12) of 16 patients.

Findings:

Review of a facility policy titled, "Medication Management," read in part, "Immediately prior to administration, the dose of medication to be administered to the patient is scanned by the individual administering the dose to confirm a medication order for that medication is on the medication profile...Immediately prior to administration of the medication, the patient's armband will be scanned to ensure the correct medication is being administered to the correct patient."

Review of a facility policy titled, "Use of Patient Identifiers," read in part, "Two patient identifiers are used when passing medications, the following identifiers are acceptable in validating a patients identity. Patient Name, Patient Hospital identification band number, Patient date of birth, and a unique identification band/number."

Patient #12

Review of the medication administration record (MAR) for Patient #12 showed Aspirin, docusate sodium, sertraline HCL, oxybutynin chloride, memantine, isosorbide mononitrate ER, gabapentin, clopidogrel bisulfate, cetirizine HCL, torsemide, entresto, eliquis, sennosides/docusate soduim, caltitrol, and amlodipine besylate administered on 10/12/2024 at 6:18 p.m. with no documentation of patient scanning prior to the medication administration resulting in patient receiving the wrong medications.


On 02/16/2024 at 10:45 AM, Staff A reviewed the MAR for Patient #16 and stated the patient and medication were not scanned prior to the medication being given resulting in patient receiving the wrong medications.