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Based on record review, observation, interview, and policy review, the facility failed to ensure the nursing staff administered medication in accordance with the administration instructions and standards of practice for 1 (SP#4) of 4 sample patients (SP).

Findings include:

Review of SP#4 Physician Order dated 05/11/2022 at 11:45 AM documented furosemide injection 40 milligrams intravenous one time.

Observation of Staff B medication administration to SP#4 on 05/11/2022 at 12:00 PM revealed Staff B verified SP#4 electronic medication administration record (eMAR) name and date of birth with patient's wristband. Staff B scanned SP#4 wristband to verify "RIGHT PATIENT" and display scheduled medications. Staff B scanned medication to verify "RIGHT DOSE" and clicked "ACCEPT." Staff B withdrew medication from vial and administered to intravenous site. Staff B stated medication administration was complete.

Staff B documented administration of medication before medication was administered.

Interview with Director of Critical Care Nursing on 05/11/2022 at 12:18 PM acknowledged medication administration was documented before medication was administered. Stated when Staff B clicked "ACCEPT" on the electronic medication administration record (eMAR) medication administration was complete.

Review of ClinDoc - Inpatient Nurse Documenting Medication Administration, Last updated 05/12/2022, documented once you scan the patient's wristband and the medication being administered, the medication administration window opens. In the administration window verify the Action, Time and Dose are correct. Click Accept to complete the documentation.

Review of PolicyStat ID 9406832, Medication Administration, Last revised: 06/2021, Documentation, H. 1. Each dose administered should be promptly documented in the Medication Administered Record (MAR or eMAR).