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Based on observations, interviews, review of medical record and incident documentation for Patients 9 and 28, review of P&Ps, and review of the hospital's POC it was determined that the hospital failed to ensure that medications were administered and managed in accordance with P&Ps.

Findings include:


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1.a. On 07/26/2022 at approximately 1700 on MN2U, an RN was observed to administer a medication to a patient. The RN used bandage scissors to cut a capsule and administer the contents to the patient.

1.b. Documentation of the physician order for the medication administered to Patient 28 on 07/26/2022 was reviewed and reflected the medication was ordered on 06/07/2022 at 1528, and was Diphenhydramine (Benadryl)/Active 50 mg Capsule oral every 6 hours, as needed for agitation, not to exceed 2 doses per day. The order included direction to "***OPEN CAPSULE***" however it did not specify to cut the capsule with bandage scissors.

1.c. The P&P titled "Medication Administration" dated 02/01/2022 reflected under the "Crushing medications" section "When not prohibited by policy, medication type, or provider order, nurses may crush medications in response to patient requests and when, in the nurse's judgement, doing so would be beneficial to the patient. If it is anticipated that the request or situation will continue or recur, the nurse should consult the provider regarding additional orders ... Only devices approved and provided by OSH may be used to crush medications ... Where used in this protocol and as appropriate to the medication involved, the term 'crush' also means to open a capsule and empty out the contents."

The P&P did not include the observed medication preparation practice of cutting a capsule with bandage scissors prior to administration of the medication within the capsule. In addition, the P&P was not fully developed as it referred to "approved and provided devices" that may be used to open a capsule and crush medications but did not include what the approved devices were; and did not include processes for cleaning the devices, and ensuring the complete dose of medication was administered when using the devices.

2.a. Refer to Tag A-144, Finding 7, regarding a suppository found in a patient bathroom, and Finding 13.a. regarding medication for Patient 9.

2.b. The P&P titled "Medication Storage and Security," dated 11/15/2021 reflected "Medications must never be left unattended ... This precludes the nurse from ... providing a patient with a dose of medication (including items such as a medicated cream or suppository) and allowing the patient to self-administer the medication without being under the direct supervision of the nurse at all times."