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Based on document review and interview, nursing services failed to document reason medications were not administered, failed to notify provider of missed medication administration, and failed to complete incident report for medications not administered for 1 of 10 (Patient 4) patient medical records reviewed

Findings include:

1. Facility policy titled, Administration of Medications, PolicyStat ID 11132380, last approved 02/2022, indicated when medications eligible for scheduled dosing time are not administered within the time period: document the reason the dose was missed or delayed. Notify the prescribing/attending physician if the delay poses an immediate patient care issue and for time critical medication delays greater than 3 hours; non-time critical medication scheduled daily, weekly, or monthly delays greater than 8 hours; and verify that the medication is administered at the appropriate time, to ensure adherence to the prescribed frequency and time of administration.

2. Facility policy titled, Incident Reports, PolicyStat ID 13033981, last approved on 01/2023, indicated that an incident is defined as: any event which is not consistent with the routine operation of the hospital and that adversely affects or threatens to affect the well-being of the patients, employees, medical staff, visitors, consultants, or property of, regardless of whether an actual injury is involved or not.

3. Review of Patient 4's medical record lacked documentation of reasons for the following medications not administered on the following dates and scheduled times, and notification of missed administration to the provider:
a. Air Duo one puff by mouth twice a day, ordered on 04/10/2024, for the 9:00 a.m. scheduled dose on 04/13/2024 and the 9:00 a.m. scheduled dose on 04/14/2024.
b. Naltrexone 50 milligram by mouth daily, ordered on 04/12/2024, for the 9:00 a.m. scheduled dose on 04/13/2024 and the 9:00 a.m. scheduled dose on 04/14/2024.
c. Nicotine Patch 21 milligram/24 hours topically, ordered on 04/10/2024, for the 9:00 a.m. scheduled dose on 04/14/2024.

4. Review of incident reports from 01/01/2024 to 05/10/2024 lacked documentation that an incident report completed for the above missed medications for Patient 4.

5. Interview with A1 (Chief Executive Officer) and A2 (Director of Quality and Infection Control) on 05/14/2024 at approximately 4:15 p.m. confirmed the following:
a. Patient 4's medical record lacked documentation of the reason medications were not administered; the medication administration record indicated that the following medications were not administered: Air Duo one puff by mouth (PO) twice a day ordered on 04/10/2024, medication administration record indicated the scheduled dose at 9:00 a.m. on 04/13/24 and 04/14/24 were not administered; Naltrexone 50 milligram by mouth daily, ordered on 04/12/2024, medication administration record indicated the scheduled dose at 9:00 a.m. on 04/13/24 and 04/14/24 were not administered; Nicotine Patch 21 mg/ 24 hours topically ordered on 04/10/2024, medication administration record indicated the scheduled 9:00 a.m. dose on 04/14/24 was not administered.
b. No incident reports were filed for the missed medications for patient 4.
c. Unable to confirm when patient 4's scheduled medications were administered due to lack of time documentation on the medication administration record.

Based on document review and interview, nursing services failed to administer ordered and scheduled medications for 1 out of 10 (Patient 4) medical records reviewed.

Findings include:

1. Facility policy titled, Administration of Medications, PolicyStat ID 11132380, last approved 02/2022, indicated verify that the medication is administered at the appropriate time, to ensure adherence to the prescribed frequency and time of administration. When medications eligible for a scheduled dosing time are not administered within the defined time period: 1. document the reason the dose was missed or delayed (i.e. patient refused, patient off unit, etc.); 2. reschedule missed or delayed doses, as appropriate.

3. Review of Patient 4's medical record lacked documentation the following medications were administered:
a. Air Duo one puff by mouth (PO) twice a day, ordered on 04/10/2024, was not administered on 04/13/24 and 04/14/24 for the 9:00 am scheduled dose.
b. Naltrexone 50 milligram by mouth daily, ordered on 04/12/2024, was not administered on 04/13/24 and 04/14/24.
c. Nicotine Patch 21 mg / 24 hours topically, ordered on 04/10/2024, was not administered on 04/14/24.

7. Interview with A1 (Chief Executive Officer) and A2 (Director of Quality and Infection Control) on 05/14/2024 at approximately 4:15 p.m. confirmed the following Patient 4's medical record lacked documentation the following medications were administered:
a. Air Duo one puff by mouth (PO) twice a day, ordered on 04/10/2024, was not administered on 04/13/24 and 04/14/24 for the 9:00 am scheduled dose.
b. Naltrexone 50 milligram by mouth daily, ordered on 04/12/2024, was not administered on 04/13/24 and 04/14/24.
c. Nicotine Patch 21 mg / 24 hours topically, ordered on 04/10/2024, was not administered on 04/14/24.

Based on document review and interview, the facility failed to document daily cleaning of patient rooms for month reviewed (April/2024).

Findings include:

1. Review of the housekeeping record sheets for April 2024, indicated lack of daily patient room cleaning documented from 4/10/2024 through 4/23/2024.

2. Interview with A1 (Chief Executive Officer), on 05/14/2024 at approximately 10:30 a.m., confirmed there were no daily patient room cleaning records from 4/10/2024 through 04/24/2024.