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Based on observation, staff interview, and medical record review the facility failed to ensure that all medications are administered in a safe manner that is consistent with professional standards.

Findings:

Observation of the medication room on 12/20/2011 at 10:20 AM with the charge nurse revealed an automated medication dispensing machine and a set of 3 trays measuring approximately 16 inches by 16 inches by 2 inches deep. The tray was divided into 2 inch by 2 inch compartments. Medication cups filled with medications were observed in several of the compartments. The medications were in their original unit dose packaging.

When the charge nurse was asked about the trays, she stated that at the beginning of each shift medications were removed from the automated machine and placed in medication cups that were labeled with the patient's name and room number. The charge nurse stated that the cups were placed in the compartment that corresponded to the patient's room. The charge nurse further stated that prior to administration to the patient and as a last check the medication was removed from the compartment and checked against the Medication Administration Record.

Observations of the charge nurse removing three cups to demonstrate the process revealed that 2 of the 3 cups removed did not have any labels with the patients' name or room number. The charge nurse stated that all the cups should be labeled with the patient's name.

When the charge nurse was asked about if she remembered a patient's concern related to medication administration, the charge nurse stated that she did remember the patient. The nurse stated that in front of the patient, the nurse checked the medications in the cup against the Medication Administration Record she realized that she had the wrong patient's medication. The charge nurse stated that the system of checks and balances worked and that a medication error was avoided.

Review of the Lippincott's Nursing Center article of Preventing adverse drug events dated March 2006 revealed, "a potential adverse drug events, (ADE), also known as a near miss, is an error that can cause injury but failed to do so by chance or because the error didn't reach the patient, (for example, because a member of the health care team caught the mistake and corrected it first)". Under ADE's and Medications errors the paper states, "Some errors result from unsafe acts that violate a policy or procedure, usually to save time or work (for example, pre-pouring medications)".

Review of a Medication Safety Alert from the Institute for Safe Medication Practices titled Guidelines for Timely Medication Administration dated 1/13/2011 revealed, "Pre-pouring medications ahead of time for one or more patients to accelerate the drug administration" is a "at risk behavior".

Review of the medical record for patient #1 revealed a nursing note dated 12/13/2011 7 A-7 P shift that stated "Patient upset with nurse passing [medications] when nurse discovered not correct pills in cup and would not give them to the patient".