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Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the Registered Nurse (RN) correctly administered medications for one (1) of ten (10) sampled patients (Patient #6).

The findings include:

Review of the facility's policy titled, "Administration of Drugs", reviewed date 01/07/12, revealed drugs should be prepared and administered in compliance with the orders of the prescriber or practitioner responsible for the patient's care and according to accepted standards of practice.

Review of Patient #6's medical record revealed the facility admitted him/her on 10/01/14, with diagnoses of Reactive Depressive Psychosis and Type 2 Insulin Dependent Diabetes. Continued record review revealed Patient #6 had orders dated 10/01/14, for Metformin (an oral hypoglycemic agent) 500 milligrams (mg) and Glipizide (an oral hypoglycemic agent) 5 mg, which were both ordered to be given twice a day, 9:00 AM and 9:00 PM. Further review of the record revealed no documented evidence Patient #6 received the 9:00 PM dose of Metformin or Glipizide on 10/02/14, and there was no documented evidence of an explanation for the missed doses of the medications on the patient's Medication Administration Record (MAR) or in the Nurse's Notes.

Interview with RN #1 on 10/23/14 at 6:10 PM, revealed she could not specifically recall if Patient #6 refused the medications at 9:00 PM on 10/02/14. She revealed if there was a missed medication, a red triangle should appear on the computer screen, and she often checked for this to ensure no medications were missed. RN #1 indicated she could offer no explanation as to why there was no documentation on the MAR of the missed doses of the Metformin and Glipizide medications.

Interview with the Chief Nursing Officer (CNO) on 10/23/14 at 6:50 PM, revealed her expectation was for nurses to review the Physician's Orders for medications as presented on the MAR and administer the medications as ordered. She stated if a medication was not given as ordered, it should be documented in the patient's chart. The CNO revealed she believed Patient #6 had refused both the Metformin and Glipizide, but the documentation of this could not be found. Per interview, if the medications had been refused by Patient #6, there should be documentation of the refusal in the medical record.