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Based on interview and record review, the facility failed to ensure that medication was administered per facility policy and professional standards for one (1) of ten sampled patients (Patient # 1).

Patient # 1 was administered hydrocodone during the 04-04-15 admission without a physician order for the medication.

Patient # 1 was administered the drug "hydrocodone" multiple times during two different admissions, despite a documented allergy to this medication.

Findings include:

TX 00228217

Admission date: 04-04-15

Record review of the clinical record of Patient # 1 revealed she was a 78 year old female admitted to the facility on 04-04-15 for rehabilitation following a right hip fracture repair.

Further review of the clinical record revealed the following:

*History & Physical exam, dated 04-05-15: ALLERGIES: The patient is allergic to HYDROCODONE..."

* Physician admission orders( dated 04-04-15) "...: Allergies...Norco ( hydrocodone)..."

*Registered Nurse (RN) Admission Assessment , dated 04-04- 15: "...Allergies: Hydrocodone.."

Review of the Medication Administration Record (MAR), dated 04-05-15, failed to reveal "hydrocodone" listed as an allergy in the space provided.

Further review of the MAR for Patient # 1 revealed Hydrocodone/APAP ( Norco) 5/325 milligram (mg) was administered 18 times between 04-06-15 and 04-20-15.

Review of all physician orders from 04-05-15 thru 04-20-15 failed to reveal an order for hydrocodone for Patient # 1.

Admission date: 05-08-15

Record review of the clinical record of Patient # 1 revealed she was a 78 year old female re-admitted to the facility on 05-08-15 for rehabilitation following a recent repair of an abdominal aortic aneurysm and a right hip fracture repair.

Further review of the clinical record revealed the following:

* Physician admission orders (dated 05-08-15) "...: Allergies...Hydrocodone.."

*Registered Nurse (RN) Admission Assessment , dated 5-08-15: "...Allergies: Hydrocodone.."

Further review of Patient # 1's physician admission orders, dated 05-08-15 read: " Hydrocodone/acetaminophen ( Norco) 5/325 mg one (1) tablet every 4 hours PRN (as needed).."

Review of the Medication Administration Record (MAR), dated 05-08-15 read: "ALLERGIES:...hydrocodone."

Further review of the MAR for Patient # 1 revealed Hydrocodone/APAP ( Norco) 5/325 milligram (mg) was administered 41 times between 05-08-15 and 05-24-15.

Interview on 01-07-16 at 2:15 p.m. with Chief Nursing Officer (CNO) # 51 she stated the medication process began with a physician order; the pharmacy generated the MAR based on the orders. CNO # 51 was unable to locate an order for the 04-04-15 admission administration of hydrocodone. She went on to say there should have been an order ; it may have been a verbal order that was not documented.

Interview on 01-07-16 at 1:45 p.m. with Quality/Risk Director # 52, she stated it was the responsibility of the admitting RN to place the appropriate allergy bands on the patient upon admission or when information becomes available. She said there was no required documentation to show a medication allergy band had been placed. The Quality Director went on to say when there was a documented medication allergy and it was ordered; the nurse should call the physician for a clarification order.

Review of facility policy titled "Medication Administration," dated 11/2014, read "Purpose: To identify verification process and information prior to medication administration...Procedure: Prior to administering medication...: A. verify the medication is correct one based on the medication order... C. MAR ..should be reviewed prior to administration...E. Verify there is no contraindication for administering the medication..."

Review of facility policy titled "Patient Alert Wristbands," dated 11/2013, read" It is the policy of Reliant to use color-coded alert wristbands as a form of critical,,necessary communication.. Color-coded wristbands should not replace verification of information in the medical record...A. Reliant will use the following color coded patient alert wristbands: Medication /Food Allergy: Red.."