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Based on record review and staff interview, one of one Patient's medical record evidenced medication entries including dosages by a Registered Nurse (#1) who did not administer the medications to the Patient who was evaluated in the Emergency Department (ED) in March 2010.

The findings are as follow:

The Patient was transported to the ED by ambulance with a complaint of dizziness.

Review of the ED Nursing Documentation indicated the Patient's vital signs on arrival were recorded as a blood pressure of 84/44 with a sinus bradycardia heart rate of 31 beats per minute. The Nursing Assessment indicated the Patient was in no apparent distress and comfortable. The Patient denied pain and there were no neurological deficits.

Review of the Medication Administration Record in the ED Nursing Documentation indicated at 8:49 PM a Dopamine drip of 5 mcg/kg/min was infused at a rate of 12. ml/hour. Registered Nurse #1 documented the administration of the medication.

Registered Nurse #1 did not administer the medication. Registered Nurse #1 said there were other nursing staff present to assist with the management of the Patient. Registered Nurse #1 identified Registered Nurse #2 as administering the medication Dopamine.

Registered Nurse #2 denied having administered the medication Dopamine.

During the course of the survey, two additional registered nurses provided care to the Patient. However, there was no clear determination made as to the identity of the registered nurse who administered the medication Dopamine.

Additionally, Registered Nurse #1 documented on 03/30/10 at 8:30 PM Zofran 4 milligrams was administered by Registered Nurse #2 and entered the initials for Registered Nurse #2 into the electronic medical record. The entry was incomplete and lacked a route of administration and a reason for the mediation. There was no documentation that the Patient complained of nausea or vomiting at the time of administration nor was there documentation for the Patient's response to the medication.

Registered Nurse #2 administered the Zofran but did not document the administration of the medication into the Patient's ED record.