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Based on observation, interview, and policy review, the provider failed to ensure medications were properly prepared and administered for two of two observed medication passes involving multiple patients. Findings include:

1. Observation on 3/15/11 at 8:30 a.m. of registered nurse (RN) A passing medications on the cedar unit revealed:
*All patient medications were prepared for administration at one time. Those medications were placed into medication cups and then into a cup holding rack were they were kept until the medication pass was complete.
*The RN did not verify the medication against the medication administration record (MAR) prior to the administration of the medication to the patients.
*The MAR was not signed by the RN after each patient received his/her medication.
*The provider utilized an Omnicell medication distribution system.

Interview on 3/15/11 at 9:00 a.m. with RN A revealed:
*Medications were always prepared for all patients prior to administration.
*Medications were only verified against the MAR at the time of medication set-up not at the time of medication administration.
*She signed the patients' MARs after all of her patients received their medications.

Interview and policy review on 3/16/11 at 9:00 a.m. with the director of quality revealed:
*The provider tracked the medication error rates on a quarterly basis. That tracking provided data that showed patients had been administered the wrong medication as well as that medications had been given to the wrong patient over the past year.
*Setting up multiple medications for multiple patients was part of the provider's current medication process and was authorized by the provider's current policies and procedures.
*She agreed the nursing process of setting-up multiple medications for multiple patients could lead to wrong patient and wrong medication, medication errors.
*She agreed the process of setting-up medications for all patients prior to administration was an antiquated method.
*She agreed MARs were to be signed at the time of medication administration and not at the end of the entire medication pass as observed above.

Interview and policy review on 3/16/11 at 9:45 a.m. with the director of clinical services revealed she agreed:
*With the statements and findings found in the interview with the director of quality.
*The setting-up of medications for all patients prior administration was not up to current clinical nursing standards but had been retained due to nursing preference.

Review of Patricia A. Perry and Anne Griffin Perry, Fundamentals of Nursing, 6th ED., St. Louis, MO., 2005, pp. 851-853, revealed:
*Medications were to be prepared for one patient at a time.
*MARs were to be signed off after administration of medications to each patient.
*Medications and MARs were to be compared for accuracy just prior to administration.




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2. Observation on 3/15/11 at 3:50 p.m. of RN B revealed she administered medications to three patients. The RN removed unit-dose medications for each patient from the Omnicell device and placed them into medication cups. After she had prepared the medications for all three patients she then administered the medications to the patients.

Based on observation, interview, and policy review, the provider failed to ensure medications were properly prepared and administered for two of two observed medication passes involving multiple patients. Findings include:

1. Observation on 3/15/11 at 8:30 a.m. of registered nurse (RN) A passing medications on the cedar unit revealed:
*All patient medications were prepared for administration at one time. Those medications were placed into medication cups and then into a cup holding rack were they were kept until the medication pass was complete.
*The RN did not verify the medication against the medication administration record (MAR) prior to the administration of the medication to the patients.
*The MAR was not signed by the RN after each patient received his/her medication.
*The provider utilized an Omnicell medication distribution system.

Interview on 3/15/11 at 9:00 a.m. with RN A revealed:
*Medications were always prepared for all patients prior to administration.
*Medications were only verified against the MAR at the time of medication set-up not at the time of medication administration.
*She signed the patients' MARs after all of her patients received their medications.

Interview and policy review on 3/16/11 at 9:00 a.m. with the director of quality revealed:
*The provider tracked the medication error rates on a quarterly basis. That tracking provided data that showed patients had been administered the wrong medication as well as that medications had been given to the wrong patient over the past year.
*Setting up multiple medications for multiple patients was part of the provider's current medication process and was authorized by the provider's current policies and procedures.
*She agreed the nursing process of setting-up multiple medications for multiple patients could lead to wrong patient and wrong medication, medication errors.
*She agreed the process of setting-up medications for all patients prior to administration was an antiquated method.
*She agreed MARs were to be signed at the time of medication administration and not at the end of the entire medication pass as observed above.

Interview and policy review on 3/16/11 at 9:45 a.m. with the director of clinical services revealed she agreed:
*With the statements and findings found in the interview with the director of quality.
*The setting-up of medications for all patients prior administration was not up to current clinical nursing standards but had been retained due to nursing preference.

Review of Patricia A. Perry and Anne Griffin Perry, Fundamentals of Nursing, 6th ED., St. Louis, MO., 2005, pp. 851-853, revealed:
*Medications were to be prepared for one patient at a time.
*MARs were to be signed off after administration of medications to each patient.
*Medications and MARs were to be compared for accuracy just prior to administration.




20880

2. Observation on 3/15/11 at 3:50 p.m. of RN B revealed she administered medications to three patients. The RN removed unit-dose medications for each patient from the Omnicell device and placed them into medication cups. After she had prepared the medications for all three patients she then administered the medications to the patients.