Observations
Based on a review of patient records, the facility failed to ensure that each dosage change is signed by the narcotic treatment physician in one of fourteen patient records.
The findings include:
Fourteen patient records were reviewed from September 16-18, 2014. All patient records were reviewed for medication orders and dosage change which shall be written and signed by the narcotic treatment physician. Patient record #9 contained documentation of medication orders that requested a dosage increase but was unsigned by a physician.
Patient #9 was admitted March 17, 2014. A dosage increase from 80 mg to 90 mg was completed on September 8, 2014, however there was no signature verifying the increase. The client began receiving 90 mg of medication on September 9, 2014 and daily thereafter.
The findings were discussed with facility staff during the inspection process.
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Plan of Correction
The narcotic treatment physician will print and sign all medical orders within 24 hours to verify dose increases or decrease ordered. The Facility Director met with the Medical Director on 9/22/14 to review this procedure.
On an ongoing basis, the Director of Nursing will review all orders to ensure that the physician signed and dated it. |