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Based on observation, interview and policy review, the facility failed to ensure the nursing staff administered medication in accordance with standards of practice for 1 (SP#4) of 4 Sampled Patients (SP).

Findings include:

Review of SP#4's Physician Order dated 10/11/2022 at 10:25 AM documented caffeine (caffeine Pedi) 5 milligram/kilogram, 4.8 milligram, 0.24 milliliters daily intravenous over 10 minutes.

Observation in the Neonatal Intensive Care Unit (NICU) of Staff B (Registered Nurse) medication administration to SP#4 on 10/11/2022 at 12:40 PM revealed Staff B (Registered Nurse) verified SP#4's electronic medication administration record (eMAR), name and date of birth. Staff B (Registered Nurse) scanned SP#4's wristband to verify "RIGHT PATIENT" and display scheduled medication. Staff B (Registered Nurse) scanned medication to verify "RIGHT DOSE." Staff C (NICU Educator) verified and witnessed medication dose calculation and co-signed. Staff B (Registered Nurse) administered medication by intravenous pump. Staff B (Registered Nurse) stated medication administration was complete.

Interview with Staff C (NICU Educator) on 10/11/2022 at 12:45 PM acknowledged medication administration was documented before medication was administered. Stated medication administration was complete when Staff B (Registered Nurse) scanned medication to verify "RIGHT DOSE" and medication calculation was verified, witnessed and co-signed.

Review of Policy No 400.025, Medication Administration, Last revised: 12/14/2021 documented, II. Procedure, D. Documentation, 2. Record medications immediately after they have been administered on the appropriate record.

Staff B (Registered Nurse) recorded administration of medication before medication was administered.