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Based on interview and record review, the Hospital failed to identify during its analysis of a medication error for one patient (Pt #1) in a total sample of ten, that the electronic medication administration record (e-MAR) indicated Pt #1 received 5 milliters (ml) of Lugol's (potassium iodine; a medication), despite special instructions within the e-MAR indicating the five drops of Lugol's can be diluted with water or juice.

Findings include:

The Hospital's internal investigation regarding the Lugol's administration error, dated 10/14/21, did not identify that the e-MAR indicated Patient #1 received five ml of Lugol's, despite the special instructions that the medication was to be adminsitered in drops.

During interview with the Pharmacy Informatics Specialist on 6/29/21, the Pharmacy Infomatics Specialist said the ml was a default in the e-MAR and will need to be corrected.

Based on observation, record review and interview the department of Nursing Services failed to ensure a cardiopulmonary resuscitation code cart was checked to ensure integrity and safety of equipment according to Hospital policy and procedure.

Findings include:

The Hospital's policy and procedure titled Code Blue Carts, not dated, indicated that designated staff must check the code cart once each open business day.

During a tour of the Gannett nursing unit at 1:00 P.M. on 6/28/21, the Surveyor observed a Code Blue Cart. On the Code Blue Cart was a Code Cart Checklist and for three days, blanks were seen indicating the cart was not checked by nursing staff on 6/11, 6/14 and 6/20/21.

During the tour of the unit the Nurse Manager said the Code Cart checks were to be performed daily and the Assistant Nurse Manager had the responsibility to ensure the checks were performed according to Hospital policy and to remind staff of their responsibility when the checks were not performed.