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Based on interview and record review, the facility failed to ensure that 1 out of 1 patients was administered a drug per the orders of the practitioner responsible for the patient's care.

Findings included:

Record review of facility's policy dated 8/22/17, titled "Policy And Procedure PC/PS200, Subject: Steps Common to the Administration of Medications ...The LHCP (licensed health care professional) must document when and why an ordered medication was not administered or was delayed".

Record review of Patient #1's orders showed there was an order on 5/9/19 for a Clonidine Patch (for blood pressure, which stays on a patient for three days) from doctor #51. Review of the Medication Administration Record (MAR) showed the patch was not given, and there were no orders to hold and not to administer the patch.

In an interview on 5/21/19 at 12:45 PM with Chief Nursing Officer, Staff # 58, she stated that if a patient had blood pressure medications ordered, most of the time the doctor will write parameters of blood pressure readings and the order would be to hold the blood pressure medication if the blood pressure was too low. She added that if the doctor did not write any parameters when to hold the blood pressure medications, then the nurse must call the doctor to get an order to hold the medication.

In a telephone interview on 5/21/19 at 1:15 PM with Staff # 54, he stated he was the nurse caring for Patient #1 and he had made a nursing judgement to hold the blood pressure medication patch because he felt the patient's blood pressure was too low, falling from 170 to 110 in approximately an hour. He stated he felt it was in the best interest of the patient and did not feel comfortable administering the drug. He added that although he was an ICU nurse and had a certain degree of autonomy, he did not realize he needed an order to hold a medication, adding "this was a shortcoming of mine".