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Based on review of medical records, policy and procedures, and staff interviews, it was determined that the facility failed to administer a medication as ordered to one (P) (P#2) of four patients (P#1, P#2, P#3, and P#4) reviewed, that led to the patient becoming tachycardic (heart rate that exceeds 100 beats per minute at rest).


Findings include:


A review of the medical record revealed that P#2 was admitted to the facility's Labor and Delivery unit on 7/7/25 at 10:39 p.m. with the chief complaint of dysmenorrhea (painful periods or menstrual cramps) and contractions every 10 minutes, which started a few hours earlier.


A review of the initial orders by Certified Nurse Midwife (CNM) EE dated 7/8/25 at 1:27 a.m. revealed an order for Terbutaline (medication used to delay preterm labor for up to 48 to 72 hours) injection 0.25mg to be administered subcutaneously (under the skin).


A review of the nursing flowsheets dated 7/8/25 revealed that P#2's heart rate at 1:50 a.m. was at 125 bpm; at 2:00 a.m. 113 bpm; at 2:15 a.m. 100 bpm; at 2:35 a.m.106 bpm; and at 3:00 a.m. 108 bpm


A review of the facility's incident report filed on 7/10/25 revealed a specific event type of an Incorrect Administration technique with a severity level of No Harm, and an event date of 7/7/25. "Brief Factual Description" revealed that Registered Nurse (RN) FF received an order to administer Terbutaline subcutaneously, but it was given intravenously; the patient became tachycardic, but no interventions were needed, and no new orders were required .


A review of the facility's "Managing Preterm Labor" nursing skills procedure stated to administer intravenous (IV) fluid and medications (as ordered and after verifying rights of safe medication administration) to stop labor and improve fetal outcomes.


A review of the facility's "Medication Management Policy", Policy #15165925, last approved 2/13/2024, stated that medication orders were reviewed for appropriate medication, dosage, frequency, route of administration, potential drug interaction, contraindications, drug allergies, etc.


During an electronic medical record review in the facility's conference room on 10/14/25 at 3:00 p.m., RN JJ confirmed that RN FF reported that she (RN FF) administered the Terbutaline medication intravenously (into a vein via an intravenous catheter) instead of subcutaneously as ordered, which led to P#2 becoming tachycardic (heart rate that exceeds 100 beats per minute - bpm).


An interview took place in the facility's conference room on 10/15/25 at 1:30 p.m. with Certified Nurse Midwife (CNM) EE, who stated that she ordered the medication (Terbutaline) to be given subcutaneously to P#2. However, RN FF reported to her (CNM EE) that she (RN FF) had mistakenly administered the medication intravenously. CNM EE stated that because the medication (Terbutaline) was administered intravenously, it had a direct effect on P#2's heart rate, increasing her heart rate. CNM EE stated that P#2 was placed on direct observation, and her heart rate decreased without interventions. CNM EE further stated that she spoke to NM II the next morning to ensure that an RL (incident report) was submitted.


An interview took place in the facility's conference room on 10/15/25 at 2:00 p.m. with Nurse Manager (NM) II, who stated that when CNM EE reported P#2's medication error incident to her, she (NM II) ensured it was documented in the incident report log. NM II recalled that during a discussion with RN FF, RN FF reported that during the medication administration process, she (RN FF) became distracted conversing with P#2 and gave the medication intravenously instead of subcutaneously. NM II further stated that RN FF received coaching to ensure such an incident does not occur again.


A telephone interview took place in the facility's conference room on 10/16/25 at 1:00 p.m. with Registered Nurse (RN) FF, who stated that the midwife had ordered a medication for P#2 to be administered subcutaneously. RN FF stated that she got distracted by talking to P#2 and mistakenly administered the medication intravenously, which led to an increase in P#2's heart rate. RN FF stated that when she realized the error, she immediately notified the charge nurse and the midwife, and P#2 was placed on observation. RN FF stated that P#2 had no further concerns and was discharged home. RN FF stated that she had a discussion with the nurse manager and received coaching.