Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 530025 (X3) Date Survey Completed 11/03/2011
Name of Provider or Supplier Ivinson Memorial Hospital Street Address, City, State 255 N 30th, Laramie, WY
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
A0405 ADMINISTRATION OF DRUGS
CFR(s): 482.23(c)(1)

Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient's care as specified under ยง482.12(c), and accepted standards of practice. (1) - All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures.


This STANDARD is not met as evidenced by:
Based on observation, patient and staff interviews, medical record review, and review of policies and procedures, the facility failed to ensure medications were administered appropriately for 1 of 19 sample patients (#2) in the facility during the survey. The findings were: During an interview with patient #2 on 10/31/11 at 3:03 PM, a bottle of "Pain Wizard" was observed on the patient's overbed table. Review of the manufacturer's label (the only label on the bottle) showed it contained the medications capsaicin, menthol, and camphor. The patient stated s/he applied the cream daily on his/her left wrist for arthritis pain from an old fracture. The patient's hand was swollen and the wrist and forearm were wrapped; the patient further stated the wrist had been re-fractured in a recent fall and the cream helped control that pain, too. Interview with RN #2, who was caring for the patient on 10/31/11 at 3:15 PM revealed she was unaware the bottle contained medications. She stated she thought the bottle was only skin softening lotion. At 3:16 PM RN #3, the unit manager, stated she was also unaware the medication was at the patient's bedside. The unit manager stated a physician's order was required before medications could be left at the bedside. After reviewing the medical record, the unit manager confirmed there was no order for self-administration of "Pain Wizard." Additionally, according to the facility's policy and procedure, "Medications Left at Patient Bedside," Number PC 77, last revised June 2011, the following guidelines were not met: a. "Medications will not be left at the patient's bedside...other than: Topical preparations for administration by nursing personnel or physicians. b. All orders will be screened by Pharmacy personnel and will be reviewed for appropriateness. c. Medications meeting the criteria will be labeled [by pharmacy] appropriately and sent to nursing units for delivery to patient's rooms. d. All self-medication doses must be recorded."