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Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.23 Nursing Services was out of compliance.

A-0392 The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. Based on interviews and document review, the facility failed to ensure patient care units had adequate numbers of licensed nursing staff, as determined by the facility staffing matrices, to provide nursing care to all patients as needed. The failure occurred in 10 of 14 shifts reviewed in which medications were administered late and in which there were gaps in the provision of bathing and/or oral care in three of five medical records reviewed (Patients #2, 3, and 5).

A-0398 All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). Based on document review and interviews, the facility failed to adhere to a policy for adequate supervision and evaluation of nursing personnel. Specifically, the facility failed to provide a policy related to the expectation for the frequency of provision of activities of daily living (ADLs) such as bathing and oral care in four of four charts reviewed in which the patient required assistance with these activities (Patients #1, 2, 3, and 5).

A-0405 (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient ' s care, and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws,
hospital policies, and medical staff bylaws, rules, and regulations. Based on document review and interviews, the facility failed to ensure medications were administered in a timely manner according to policy and national guidelines in four of four medical records reviewed showing medications were administered off schedule (a warning in the medical record that a medication was being administered outside of the allotted timeframe) (Patients #1, 2, 3, and 5).

Based on interviews and document review, the facility failed to ensure patient care units had adequate numbers of licensed nursing staff, as determined by the facility staffing matrices, to provide nursing care to all patients as needed. The failure occurred in 10 of 14 shifts reviewed in which medications were administered late and in which there were gaps in the provision of bathing and/or oral care in three of five medical records reviewed (Patients #2, 3, and 5). [Cross-reference A-0398 and A-0405]

Findings include:

Facility policy:

According to the Timely Medication Administration policy, supporting operational guidelines for timely administration of scheduled medications: Maintain adequate staffing levels in the pharmacy and patient care units, based on workload and patient acuity, to facilitate timely order review, dispensing, drug administration, and patient monitoring. Consider medication administration when making patient assignments. When planning nursing staff assignments for patient care, consider the following patient acuity factors: Types of prescribed medications, quantity of time-critical medications, the complexity of drug delivery devices, verification processes, administration, and the patient's ability to swallow oral medications.

Administer time-critical scheduled medications at the exact time indicated when necessary or within 30 minutes before or 30 minutes after the scheduled time. Examples of time-critical medications included antiepileptics.

Administer non-time critical medications daily, weekly, or monthly within two hours before or after the scheduled time. Although it is generally safe to administer daily/weekly/monthly medications within a time frame that exceeds two hours, the Institute of Safe Medical Practices (ISMP) recommends keeping the time frame to two hours before or after the scheduled time to prevent accidental omission of doses that might be more easily forgotten if delayed more than two hours.

Non-time critical medications administered more frequently than daily but not more frequently than every four hours (e.g., two times per day (BID), three times per day (TID), every four hours (Q4H), every six hours (Q6H)) should be administered within one hour before or after the scheduled time.

Reference:

According to the facility document Staffing Guideline, the clinical manager or assistant nurse manager will staff to the average daily census unit staffing plan. The staffing plan is created collaboratively with unit/department leadership and frontline caregivers. Only staffing plans created through the formal approval structure should be used. The staffing plan guides the numbers of caregivers at each census level. The clinical manager or assistant nurse manager must plan adequate coverage for individual unit/department staffing 24/7.

1. The facility failed to ensure adequate numbers of registered nurses in accordance with the staffing matrices to provide timely medication administration and assistance with activities of daily living (care such as bathing and oral hygiene) in the ortho/spine, surgical, and telemetry patient care units.

A. A total of 14 shifts were assessed for adequate staffing. These shifts were the day and night shifts of 9/7/22, 9/19/22, 9/30/22, 10/13/22, 11/3/33, 11/5/22, and 11/8/22. Of these 14 shifts, 10 had inadequate staffing according to the staffing matrices. Medical record reviews of patients receiving care during the 10 shifts with inadequate staffing showed a failure of staff to administer medications within the timeframe specified by policy and a failure to provide bathing and/or oral care. For example:

i. A review of Patient #2's medical record revealed she was admitted to the ortho/spine unit from 8/29/22 to 9/21/22. The record review further revealed that throughout her admission, according to the Timely Medication Administration policy, nursing staff administered medications late to Patient #2 on 11 occasions. From those instances of late medication administration, the dates of 9/7/22 and 9/19/22 were randomly chosen for assessment of nurse staffing levels. The ortho/spine staffing matrix (a document developed by the facility to guide numbers of bedside staff based on the number of admitted patients) revealed the unit was not adequately staffed on those days. For example:

a. On the night shift of 9/7/22, the staffing matrix called for six RNs with four RNs actually staffed. During that shift staff administered midodrine (a medication used to support blood pressure) per mouth that had been ordered twice a day to Patient #2. Patient #2 received the medication 20 minutes past the time frame allotted by the policy.

b. On the day shift of 9/19/22, the staffing matrix called for five RNs with four RNs actually staffed. On 9/19/22 Patient #2 had two medications administered late on the day shift, including midodrine per mouth which had been ordered three times a day. The dose was administered 23 minutes past the time frame allotted by the policy.

ii. A review of Patient #3's medical record revealed he had been admitted to the surgical unit from 9/23/22 to 10/13/2. The record review further revealed nursing staff administered medications late to Patient #3 19 times throughout his admission. From the instances of late medication administration, the date of 9/30/22 was randomly chosen for assessment of nurse staffing levels.

a. The surgical staffing matrix revealed the unit was not adequately staffed, as on the night shift of 9/30/22 the matrix called for six RNs, with five RNs actually staffed. On 9/30/22 Patient #3 had two medications administered late on the night shift, including apixaban (a blood thinner used to prevent clots) per mouth that had been ordered twice a day. The dose was administered 11 minutes past the time frame allotted by the policy.

b. The medical record indicated Patient #3 required assistance with bathing and oral care. Medical record review revealed Patient #3 experienced gaps in the provision of bathing and oral care on 9/30/22. Patient #3's chart did not include documentation of a bath between 9/29/22 and 10/3/22. Additionally, no oral care for Patient #3 was documented between 9/27/22 and 10/9/22.

iii. A review of Patient #5's medical record revealed he had been admitted to the telemetry unit from 11/2/22 to 11/20/22. The record review further revealed nursing staff administered medications late to Patient #5 nine times throughout his admission. From the instances of late medication administration, the dates of 11/3/22, 11/5/22, and 11/8/22 were randomly chosen for assessment of nurse staffing levels.

a. The telemetry staffing matrix revealed the unit was not adequately staffed. For example, on the 11/3/22 day shift the staffing matrix called for six RNs, with five RNs actually staffed. On 11/3/22 Patient #3 had three medications administered late on the day shift, including pantoprazole (an antacid medication used to prevent the stomach from developing ulcers and treat acid reflux) per mouth that had been ordered twice a day. The dose was administered 50 minutes past the time frame allotted by the policy.

On the 11/5/22 day shift the staffing matrix called for six RNs, with five RNs actually staffed. On 11/5/22 Patient #3 had one medication administered late on the day shift. This was heparin (a blood thinner to prevent clots) injected into the skin that had been ordered three times a day. The dose was administered six minutes past the time frame allotted by the policy.

On the 11/8/22 day shift the staffing matrix called for five RNs, with four RNs actually staffed. On 11/8/22 Patient #3 had one medication administered late on the day shift. This was pantoprazole per mouth that had been ordered twice a day. The dose was administered 18 minutes past the time frame allotted by the policy.

b. The medical record indicated Patient #5 required assistance with bathing and oral care. Medical record review revealed Patient #5 experienced gaps in the provision of that care. Patient #5 did not have a bath documented between 11/6/22 through 11/11/22, which included the randomly selected 11/8/22 staffing matrix review date. Patient #5's medical record also revealed he had no documented oral care from 11/4/22 to 11/11/22, which included the randomly selected 11/5/22 and 11/8/22 staffing matrix review dates.

The lack of adequate staffing according to the staffing matrices for the ortho/spine, surgical, and telemetry units was in contrast to the facility Staffing Guideline, which read the clinical manager or assistant nurse manager should have staffed to the daily census unit staffing plan. The staffing plan was created collaboratively with unit/department leadership and frontline caregivers. The staffing plan guided numbers of caregivers at each census level. The clinical manager or assistant nurse manager should have planned adequate coverage for individual unit/department staffing through all hours of the day.

B. Interviews

i. On 12/19/22 at 11:39 a.m., an interview was conducted with RN #1. RN #1 stated as part of their expected job duties, nurses needed to help with activities of daily living (personal care activities such as bathing and performing oral care)(ADLs). RN #1 explained oral care should have been provided at least once a day. She further stated baths should have been provided every day or every other day, and if this was not done there was a risk to patients of skin breakdown, infection, and longer hospital stays leading to higher costs to the patient and the hospital. RN #1 explained the facility had made efforts to increase staffing but the unit was still short of staff, causing existing staff to have to find flexibility with patient care duties. She further explained staffing levels on the telemetry unit continually fluctuated.

ii. On 12/19/22 at 12:27 p.m., an interview was conducted with RN #2. RN #2 explained baths may not have been completed if staffing was not adequate. She further explained adequate staff was necessary to complete hourly rounding on patients, during which bedside staff addressed ADLs and other patient care needs. RN #2 said nurses worked to fill in the gaps, but that ADLs had not always been performed as needed by all patients. RN #2 said the lack of nursing staff made it difficult to complete the hourly rounding, and that nurses were expected to take a higher number of patients.

Additionally, RN #2 stated the lack of staffing caused delays in medication administration. RN #2 said having daily medications all scheduled at the same time of the day caused a strain on nursing resources when staffing was short and nurses were required to have an increased patient load.

RN #2's concern with staffing levels contributing to late medication administration was in accordance with the facility policy Timely Medication Administration, which read the facility should have maintained adequate staffing levels in the pharmacy and patient care units, based on workload and patient acuity, to have facilitated timely order review, dispensing, drug administration, and patient monitoring. Leadership staff should have considered medication administration when they made patient assignments. When planning nursing staff assignments for patient care, leadership staff should have considered the following patient acuity factors: Types of prescribed medications, quantity of time-critical medications, the complexity of drug delivery devices, verification processes, administration, and the patient's ability to swallow oral medications.

iii. On 12/19/22 at 10:45 a.m., an interview was conducted with RN # 7. RN #7 stated she felt the current staffing levels were not safe, as recently nurses were required to take an increased patient load.

iv. On 12/22/2022 at 10:48 a.m., an interview was conducted with the director of nursing (DON) #3. DON #3 explained the staffing matrices were a plan and a guideline that had been developed with the participation of the frontline nurses. She stated the number of expected RNs was based on how many hours of care each patient would require in a day. She stated the facility was not always able to meet the goal of the staffing matrix.

v. On 12/21/2022 at 11:31 a.m., an interview was conducted with the director of acute care services (Director) #4. Director #4 stated bathing patients was important as the skin was the largest body organ. She further stated it was important to keep patients clean as patients with medical access lines, such as intravenous access or urinary catheters, were at a higher risk for infections. Director #4 explained that baths were particularly important for patients with wounds as lack of hygiene would impair the healing process.

vi. On 12/21/2022 at 10:58 a.m., an interview was conducted with the director of pharmacy (Director) #5. Director #5 stated it was important to administer medications on the intended schedule so the medications would have the appropriate therapeutic actions. He explained the purpose of drug administration timing windows was to ensure the intent of the physician's order was carried out while allowing nursing staff to care for multiple patients.

Based on document review and interviews, the facility failed to adhere to a policy for adequate supervision and evaluation of nursing personnel. Specifically, the facility failed to provide a policy related to the expectation for the frequency of provision of activities of daily living (ADLs) such as bathing and oral care in four of four charts reviewed in which the patient required assistance with these activities (Patients #1, 2, 3, and 5).

Findings include:

References:

According to the facility document Skills: Bathing: Tub Baths and Showers, patients who are incontinent of urine or stool require more frequent perineal care. Patients who are incontinent of urine or stool should be bathed after each elimination to reduce prolonged skin exposure to moisture. For a patient with an indwelling catheter, the urethral meatus should be cleansed daily with soap and water as part of overall patient hygiene. Antiseptic cleansers are not recommended for use with patients who have an indwelling
urinary catheter because irritation of the urethral meatus may increase the risk of infection. Document the procedure in the patient's record.

According to the facility document Skills: Bathing: Bed Bath, bathing provides an opportunity for the health care team member to assess the overall condition of the patient's skin, including its integrity, turgor, and color, and to detect abnormalities (e.g., petechiae, rash, bruising). Application of friction or force to the skin and massaging of reddened areas should be avoided. To further reduce the risk of skin injury, the health care team member should minimize pressure over bony prominences and dry the skin by patting, not rubbing. Patients who are incontinent of urine or stool require more frequent perineal care. Perineal care, which involves thorough cleansing of the patient ' s external genitalia and surrounding skin, should be performed during the bath. Document the procedure in the patient ' s record.

1. The facility failed to provide a policy and/or other guidance for staff related to the frequency of performing patient ADLs such as bathing and oral care.

A. Document review

i. When requested, the facility was unable to provide a policy or documentation to guide the frequency of the provision of bathing and oral care.

ii. A focused review for bathing in the medical records of Patients #1, 2, 3, and 5 was performed with the assistance of registered nurse clinical informaticist (RN) #6. The medical records were further reviewed for the provision of oral care.

a. Record review revealed Patient #1 was admitted from 11/11/22 to 11/17/22. An occupational therapy evaluation dated 11/14/22 noted the patient needed some assistance with bathing and required cueing to perform oral care. The medical record did not include documentation of bathing or cueing to perform oral care during Patient #1's admission.

b. Record review revealed Patient #2 was admitted from 8/29/22 to 9/21/22. An occupational therapy evaluation dated 9/5/22 noted the patient was unable to bathe independently and needed a lot of assistance to perform personal grooming and oral care. Occupational therapy also noted Patient #2 was incontinent. No bathing or perineal care (washing of the patient's genitals and rectal area) was documented between 9/15/22 to 9/17/22. Additionally, no oral care was documented between 9/3/22 to 9/6/22.

These findings were in contrast to the facility document Skills: Bathing: Tub Baths and Showers, which read patients who were incontinent of urine or stool required more frequent perineal care. Patients who were incontinent of urine or stool should have been bathed after each elimination to reduce prolonged skin exposure to moisture. The bath should then have been documented in the patient's medical record. They were also in contrast to the facility document Skills: Bathing: Bed Bath, which read patients who were incontinent of urine or stool required more frequent perineal care. Perineal care, which involved thorough cleansing of the patient ' s external genitalia and surrounding skin, should have been performed during the bath. The procedure should then have been documented in the patient ' s medical record.

c. Record review revealed Patient #3 was admitted from 9/23/22 to 10/13/22. An occupational therapy evaluation dated 9/25/22 noted the patient was unable to bathe independently and needed a lot of assistance to perform oral care. Occupational therapy also noted Patient #3 was incontinent. No bathing was documented from 9/23/22 to 9/25/22, 9/29/22 to 10/3/22, and 10/6/22 to 10/13/22. Additionally, no oral care was documented between 9/27/22 to 10/9/22.

These findings were in contrast to the facility document Skills: Bathing: Tub Baths and Showers, which read patients who were incontinent of urine or stool required more frequent perineal care. Patients who were incontinent of urine or stool should have been bathed after each elimination to reduce prolonged skin exposure to moisture. The bath should then have been documented in the patient's medical record. They were also in contrast to the facility document Skills: Bathing: Bed Bath, which read patients who were incontinent of urine or stool required more frequent perineal care. Perineal care, which involved thorough cleansing of the patient's external genitalia and surrounding skin, should have been performed during the bath. The procedure should then have been documented in the patient's medical record.

d. Record review revealed Patient #5 was admitted from 11/2/22 to 11/20/22. An occupational therapy evaluation dated 11/3/22 noted the patient needed a lot of assistance with bathing and a little assistance with oral care. No bathing was documented between 11/6/22 through 11/11/22. Additionally, no assistance with oral care was documented from 11/4/22 through 11/11/22.

B. Interviews

i. On 12/19/22 at 10:45 a.m., an interview was conducted with RN # 7. RN #7 stated the facility had no specific expectation for bathing or performing oral care for patients. RN #7 stated on the ortho/spine unit, where she worked, bathing and oral care were offered on a case-by-case basis. She explained on the ortho/spine unit many patients were independent and had short hospital stays. However, in the case where patients were restricted to bed and had longer admissions, bathing should have been offered nightly. RN #7 stated bathing was documented in the Cares and Safety Flowsheets section in the medical record. RN #7 explained if the patient needed assistance with oral care, it should have been offered daily. RN #7 said patients were at risk for infection if bathing and oral care were not performed.

ii. On 12/19/22 at 11:18 a.m., an interview was conducted with certified nurse assistant (CNA) #8. CNA #8 stated on the ortho/spine unit bathing was expected to be offered each morning and documented on the Cares and Safety Flowsheets section of the medical record. CNA #2 further stated if the patient refused the offered bath, the refusal was documented in the Cares and Safety Flowsheets section of the medical record. CNA #2 said oral care was offered in the morning and documented in the Cares and Safety Flowsheets section of the medical record. CNA #2 further said a patient was at risk of skin breakdown, infection, and mouth sores if ADLs were not performed to the patient's needs.

iii. On 12/19/22 at 12:01 p.m., an interview was conducted with RN #9. RN #9 said on the telemetry unit, washing and toileting for patients occurred three times a day and oral care was offered daily. RN #3 stated ADLs were documented in the Cares and Safety Flowsheets section of the medical record, including refusals. RN #9 stated a patient was at risk for skin breakdown and infection if ADLs were not performed.

iv. On 12/21/2022 at 10:58 a.m., an interview was conducted with RN #2. RN #2 stated in the intensive care unit (ICU), baths should have been offered daily. She further stated that in the ICU there was no formal policy for bathing. RN #2 expressed concern that in the ICU there was not a safe method for providing oral care, as many patients had an aspiration (unintended movement of a foreign object into the airway) risk. RN #2 stated oral care was documented under the Cares and Safety Flowsheet in the electronic medical record, and that if it was not documented there it was considered to not have been performed.

v. On 12/21/2022 at 4:10 p.m., an interview was conducted with the director of acute care services (Director) #4. Director #4 stated staff bathing patients and performing oral care was dependent on the unit and on patient characteristics. She explained that staff performing baths and oral care might be communicating to each other in verbal reports between shifts if these activities had been performed. Director #4 stated understanding how frequently it was reasonable to perform baths and oral care was a facility gap in expectations. Director #4 stated a patient going longer than a few days without bathing or oral care was not reasonable.

vi. On 12/21/2022 at 4:10 p.m., an interview was conducted with the director of quality and patient safety (Director) #10. Director #10 stated the facility did not have a policy to guide the provision and frequency of bathing and ADLs. Director #10 explained the facility potentially had a gap in clarifying expectations for the provision of bathing and other ADLs. Director #10 stated a patient going longer than a few days without bathing or oral care was not reasonable.

Based on document review and interviews, the facility failed to ensure medications were administered in a timely manner according to policy and national guidelines in four of four medical records reviewed showing medications were administered off schedule (a warning in the medical record that a medication was being administered outside of the allotted timeframe) (Patients #1, 2, 3, and 5).

Findings include:

Facility policy:

According to the Timely Medication Administration policy, supporting operational guidelines for timely administration of scheduled medications: Maintain adequate staffing levels in the pharmacy and patient care units, based on workload and patient acuity, to facilitate timely order review, dispensing, drug administration, and patient monitoring. Consider medication administration when making patient assignments. When planning nursing staff assignments for patient care, consider the following patient acuity factors: Types of prescribed medications, quantity of time-critical medications, the complexity of drug delivery devices, verification processes, administration, and the patient's ability to swallow oral medications.

Administer time-critical scheduled medications at the exact time indicated when necessary or within 30 minutes before or 30 minutes after the scheduled time. Examples of time-critical medications included antiepileptics.

Administer non-time critical medications daily, weekly, or monthly within two hours before or after the scheduled time. Although it is generally safe to administer daily/weekly/monthly medications within a time frame that exceeds two hours, the Institute of Safe Medical Practices (ISMP) recommends keeping the time frame to two hours before or after the scheduled time to prevent accidental omission of doses that might be more easily forgotten if delayed more than two hours.

Non-time critical medications administered more frequently than daily but not more frequently than every four hours (e.g., two times per day (BID), three times per day (TID), every four hours (Q4H), every six hours (Q6H)) should be administered within one hour before or after the scheduled time.

Reference:

The Institute for Safe Medication Practices (January 12, 2011) Guidelines for Timely Administration of Scheduled Medications (Acute) retrieved from the Timely Medication Administration policy at https://www.ismp.org/guidelines/timely-administration-scheduled-medications-acute read, in general, the guidelines represent a safe, effective, and efficient approach to timely administration of scheduled medications. Time-critical scheduled medications are those where early or delayed administration of maintenance doses of greater than 30 minutes before or after the scheduled dose may cause harm or result in substantial sub-optimal therapy or pharmacological effect. Non-time critical scheduled mediations are those where early or delayed administration within a specified range of either 1 or 2 hours should not cause harm or result in substantial sub-optimal therapy or pharmacological effect.

Establish guidelines that facilitate administration of the hospital-identified, time-critical scheduled medications at the exact time indicated when necessary or within 30 minutes before or 30 minutes after the scheduled time(or more exact timing when indicated, as with rapid-, short-, and ultra-short-acting insulins).

Establish guidelines for daily, weekly, or monthly medications. Administer these medications within 2 hours before or after the scheduled time. Although it is generally safe to administer daily/weekly/monthly medications within a timeframe that exceeds 2 hours, ISMP recommends keeping the timeframe to 2 hours before or after the scheduled time to prevent accidental omission of doses that might be more easily forgotten if delayed more than 2 hours.

Medications administered more frequently than daily but not more frequently than every 4 hours (e.g., BID, TID, Q4H, Q6H) Administer these medications within 1 hour before or after the scheduled time.

1. The facility failed to ensure medications were administered in a timely manner according to policy and national guidelines in the telemetry, ortho/spine, and surgical units.

A. Document review

i. A review of Patient #1's medical record revealed he was admitted to the telemetry unit from 11/11/22 to 11/17/22. The medical record was further reviewed for off-schedule medications (a warning the electronic medical record gave to staff that the medication was being administered at a time outside of the accepted time frames).

The medical record review revealed through his hospital course, nursing staff administered medications late to Patient #1 ten times. Examples included:

a. According to the Timely Medication Administration policy levetiracetam (an antiepileptic) should have been administered 30 minutes before or 30 minutes after the scheduled time. On 11/15/22 nursing staff administered levetiracetam to Patient #1 two hours and two minutes after the scheduled time.

b. According to the Timely Medication Administration policy metoprolol (a medication to control heart rate and blood pressure), ordered twice a day, should have been administered one hour before or one hour after the scheduled time. On 11/12/22 nursing staff administered metoprolol to Patient #1 two hours and forty minutes after the scheduled time.

ii. A review of Patient #2's medical record revealed she had been admitted to the ortho/spine unit from 8/29/22 to 9/21/22. The review further revealed nursing staff administered medications late to Patient #2 11 times throughout her admission. Examples included:

a. According to the Timely Medication Administration policy furosemide (a medication to decrease the amount of fluid in the body), ordered twice a day, should have been administered one hour before or one hour after the scheduled time. On 9/14/22 nursing staff administered furosemide to Patient #2 one hour and twenty-five minutes after the scheduled time.

b. According to the Timely Medication Administration policy midodrine (a medication to increase blood pressure), ordered three times a day, should have been administered one hour before or one hour after the scheduled time. On 9/19/22 nursing staff administered midodrine to Patient #2 one hour and twenty-three minutes after the scheduled time.

iii. A review of Patient #3's medical record revealed he had been admitted to the surgical unit from 9/23/22 to 10/13/22. The review further revealed nursing staff administered medications late to Patient #3 19 times throughout his admission. Examples included:

a. According to the Timely Medication Administration policy ciprofloxacin (an antibiotic), ordered twice a day, should have been administered one hour before or one hour after the scheduled time. On 10/6/22 nursing staff administered ciprofloxacin to Patient #3 one hour and twenty-four minutes after the scheduled time.

b. According to the Timely Medication Administration policy olanzapine (a medication to prevent psychosis), ordered twice a day, should have been administered one hour before or one hour after the scheduled time. On 10/9/22 nursing staff administered olanzapine to Patient #3 two hours and thirty-six minutes after the scheduled time.

iv. Similar findings were in the medical record of Patient #5, who had been admitted to the telemetry unit from 11/2/22 to 11/20/22. Medical record review revealed nursing staff administered medications late to Patient #5 nine times throughout his admission.

The findings in the medical records of Patients #1, 2, 3, and 5 were in contrast to the Institute for Safe Medication Practice's (ISMP) Guidelines for Timely Administration for Scheduled Medications (Acute), which read in general, the guidelines represented a safe, effective, and efficient approach to timely administration of scheduled medications. The guideline recommended time-critical, scheduled medications have been administered at the exact time indicated or within 30 minutes before or 30 minutes after the scheduled time.

For non-time-critical daily, weekly, or monthly medications, the guideline recommended medications have been administered within 2 hours before or after the scheduled time. For non-time-critical medications administered more frequently than daily but not more frequently than every 4 hours, the guideline recommended the medication have been administered within 1 hour before or after the scheduled time.

B. Interviews

i. On 12/21/2022 at 10:58 a.m., an interview was conducted with registered nurse (RN) #2. RN #2 stated it was important for patients to have received their medications within the scheduled time frames to allow for efficacy. She explained if medications were not provided as scheduled, the patient's blood level of that medication would have been inappropriately increased or decreased.

ii. On 12/21/2022 at 10:58 a.m., an interview was conducted with the director of pharmacy (Director) #5. Director #5 stated it was important to administer medications on the intended schedule so the medications would have the appropriate therapeutic actions. He explained the purpose of drug administration timing windows was to ensure the intent of the physician's order was carried out while allowing nursing staff to care for multiple patients.

Director #5 stated the facility followed ISMP guidelines for medication administration. He also stated the electronic medical record was designed to follow the facility's policy and national guidelines. Director #5 explained the medical record would warn staff with an off-schedule medication alert if staff gave medication outside of the accepted time frames.