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Based on document review and interview, the registered nurse failed to ensure patients medication was given as ordered by the physician for 1 of 11 patient's (P#2). See Tag A0405

The cumulative effect of this deficient practice prevented the facility from providing a safe environment by the nursing staff.

Based on document review and interview, the registered nurse failed to ensure patients medication was given as ordered by the physician for 1 of 11 patients (P#2).

Findings include:

1. Review of the policy titled "Medication and Intravenous Therapy Administration Documentation (D), 3075", PolicyStat ID: 12583523, last revised 06/2022 indicated the purpose to provide an accurate daily permanent record of medication and intravenous therapy administration, medications are documented by using bedside computer documentation with barcoding. Page 2. 4. Administer medications utilizing 5 rights.
a. Right Patient
b. Right Medication
c. Right dose
d. Right time
e. Right route
Page 3. 1. Medications may have one or both of the following barcodes: b. Scanning the patient's armband will verify the patient. Scanning the manufacturer barcode will verify the correct medication, as an error could occur in the process of pharmacy labeling. If the medication barcode will not scan, contact pharmacy.

2. Review of medical record for P#2 medical indicated the patient had a order written on 01/01/2024 at 0453 for norepinephrine additive 8 mg (milligram) plus sodium chloride 250 ml (milliliter), Intravenous (IV). The MR indicated that norepinephrine was administered to P#2 on 01/01/2024 at 0512 hours.

3. Review of the Override Medication Scan Reason Report dated 01/01/2024 indicated when attempting to administer P#2 medications, the medication that was scanned by N2 (Registered Nurse) with the barcode was nicardipine 50 mg and sodium chloride 0.9% 250 ml on 01/01/2024 at 0512 hours producing an error code. N2 overrode this error message by selecting norepinephrine from the P#2 ordered medication list on the computer screen. N2 proceeded by administering the incorrect medication without a provider's order.

4. Interview on 03/13/2024 with A1 (Chief Nursing Officer) at 0915 hours, confirmed that the facility failed to administer the correct medication as ordered (Norepinephrine) and the incorrect medication (Nicardipine) was administered to P#2.