HospitalInspections.org

Based on policy review, personnel record review, medical record review, and interview, the hospital failed to provide medication-related services by qualified personnel in accordance with Federal and State laws and accepted standards of practice for 1 (Patient 1) of 3 sampled patients. This deficient practice increases the risk of medication errors that could negatively impact the health and well-being of any patient receiving services at this hospital.

Findings Include:

Review of a hospital policy titled, "Medication Administration," reviewed on 10/30/25, showed " ...The following categories of personnel may administer medications within their scope of practice, training and expertise. 1. Registered Nurse 2. Licensed Practical Nurse 3. X-Ray Technologist, Registered 4. Nuclear Medicine Technologist, Registered 5. Respiratory Therapist, Certified, Registered or Licensed 6. Physical Therapist, Registered 7. Speech Therapist, Certified 8. Occupational Therapist, Registered 9. Pharmacists ..."

Patient 1

Review of Patient 1's medication administration record (MAR) on 11/21/25 at 11:10 AM, showed that Staff D, Nurse Technician, administered acetaminophen 500 mg (medication to treat pain/fever) and a pain assessment. The review of the MAR failed to show documented evidence that the medication administration was supervised by a Registered Nurse (RN).

Review of Staff D's personnel record failed to show documented evidence of facility-validated competencies for medication administration and/or pain assessments.

During an interview on 12/10/25 at 12:20 PM, Staff E, Chief Nursing Officer (CNO), and Staff G, Director of Orthopedic and Telemetry, confirmed that Nurse Technicians were permitted to administer medications upon completion of nursing school competencies. Staff E stated that the hospital did not complete or maintain facility-validated competencies for the Nurse Technician role and relied on school-based competencies to determine qualification.