109.65 Recording of drugs administered
(a) Each dose of drug shall be
recorded in the medical record of the
patient and properly signed after the
drugs have been administered.
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Observations:
Based on a review of facility documents and medical records (MR), it was determined that the facility failed to administer medications within one hour before or after the scheduled time as per facility policy in one of one medical record reviewed (MR1).
Findings include:
On May 9, 2024, at approximately 10:30 AM review of policy M01-N Medication Administration (last revised 1/1/2024) was completed and revealed: " ...14: Follow the "6 Rights." of medication administration. Administer: I. The right medication. II. At the Right time. III. In the Right dose. IV. To the Right Patient. V. By the Right route. VI. In the Right Circumstance ... Policy 17: Medications will be administered at standard times unless specifically ordered by the physician. (See M02-N Medications: Standard Administration Times). ... "
On May 9, 2024, at approximately 10:30 AM review of policy M02-N Medications: Standard Administration Times (last reviewed 07/2023), was completed and revealed: " ...Procedure: Standard Administration Times for Scheduled Medications (4): Non-time Critical Scheduled Medications with a frequency of every 4 hours or greater, will be administered within 1 hour before or after the scheduled time ...Missed or Late Administration of Medications (3): If the patient/medication becomes available and the dosing interval is more than 50% past, then the dose will be continued at the next prescribed time ...(3)(b): If the medication is given and future doses need to be rescheduled, this should be documented in the MAR. ... "
On May 9, 2024, at approximately 10:45 AM review of policy M02-a-N Medications: Standard Administration Times Addendum (last revied 4/2022) was completed and revealed: " Purpose: To define hospital-wide scheduled medication administration times. Procedure: Daily or Q24h-1000; Daily PM or QHS-2200; ... BID (twice a day) or Q12hours-1000, 2200; ...TID (3 times a day) or Q8hours-0600, 1400, 2200; ...With meals-0800, 1200, 1700 adjusted based on meal tray times ... "
On May 9, 2024, a review of the Medication Administration Record (MAR) for April 21, 2024, for MR1 revealed that an antibiotic (BACTRIM) ordered PO (by mouth) every 12 hours (10 AM, 10 PM) was offered at 2:06 PM, four hours after the scheduled time. Continued review of MR1's MAR revealed seven other medications were not offered at the ordered time on April 21, 2024.
On May 9, 2024, a review of the MAR for April 22, 2024, for MR1 revealed that a blood thinner (Eliquis) ordered per tube BID (twice a day at 10 AM, 10 PM) was offered at 11:27 AM, over one hour past the scheduled time. Continued review revealed five other medications were not offered at the ordered time on April 22, 2024.
On May 9, 2024, a review of the MAR for April 23, 2024, for MR1 revealed that a probiotic ordered 3x Daily with meals (8AM, 12 PM, 5PM) was offered at 10:36 AM and 7:13 PM, over two hours past the scheduled time. Continued review revealed two other medications were not offered at the ordered time on April 23, 2024.
On May 9, 2024, a review of the MAR for April 25, 2024, for MR1 revealed that an anticonvulsant (Neurontin) ordered TID (3x daily at 6 AM, 2 PM, 10 PM) was offered at 3:11 PM, over one hour past the scheduled time. Continued review revealed three other medications were not offered at the ordered time on April 25, 2024.
On May 9, 2024, a review of the MAR for April 29, 2024, for MR1 revealed that a blood thinner (Eliquis) ordered per tube BID (twice a day at 10 AM, 10 PM) was offered at 12:58 PM, three hours past the scheduled time. Continued review revealed six other medications were not offered at the ordered time on April 29,2024.
On May 9, 2024, at 1 PM, a review of the MAR dating April 21, 2024, through May 1, 2024, revealed that the patient did not receive medications on time in eight of the nine days reviewed.
On May 9, at 1333, EMP3 confirmed the above findings.
| | Plan of Correction - To be completed: 08/01/2024
To ensure medications are administered and recorded properly in accordance with 109.36 LICENSURE Recording of Drugs Administered, the Chief Nursing Officer (CNO), and/or designee, will provide education to clinical nursing staff on Clinical Services Policy and Procedure Number M01-N, "Medication Administration" and M02-N, "Medication Standard Administration Times", with emphasis on, medication administration – within one hour before or after the scheduled time. Education will be completed no later than August 1, 2024. As of August 1, 2024, any nursing staff members that have not completed this education will do so prior to working their next scheduled shift
Compliance with the above plan will be monitored by the CNO, or designee.
To ensure documentation in the medical record of timely medication administration, the CNO, or designee, will audit 5 medical records a day. This will continue until 90% compliance has been achieved and sustained. At that time, monitoring will be part of the hospital's ongoing Quality Assurance Process Improvement (QAPI) Plan via random audits. Findings will be reported monthly to the QAPI Team, and quarterly to the Organization Improvement Committee (OIC), Medical Executive Committee (MEC) and Governing Board (GB). Staff members who are noted to be non-compliant will be subject to disciplinary action, up to and including termination, per HR policies and procedures.
The Chief Nursing Officer is ultimately responsible for ensuring the plan of correction is implemented and that compliance is achieved and maintained.
The hospital will be in full compliance with the above by August 1, 2024
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