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Based on a review of policy and procedures, medical records, and staff interviews, it was determined that the facility failed to ensure that nursing staff administered medications using appropriate patient identifiers and per physician's orders when:
1. One (P#4) of five (P#1, P#2, P#3, and P#5) patients reviewed received another patient's medications.
2. One (P#1) of five (P#2, P#3, P#4, and P#5) patients reviewed failed to receive two doses of an ordered antibiotic

Findings included:

A review of the facility's policy titled, "Medication Management and Documentation", date of issue: 8/2020, revealed the following:
Procedure:
1. Orders
a. Only Practitioners who are lawfully authorized to prescribe and privileged to practice at this Hospital may write medication orders.
b. Medication orders are to be reviewed by the Pharmacists for appropriateness of all medication orders prior to dispensing by the Pharmisit.
2. Administration
a. a. No drugs shall be administered except by licensed personal authorized to administers upon the order of a person lawfully authorized to prescribe.
b. e. Medication should be administered as soon as possible after being prepared.
c. g. Any nurse administering medications has the right to refuse to do so if there is any question regarding the safety of administering the medication. The physician will be notified of why the medication was not given.
d. i. Report drug administration errors and adverse or untoward drug reactions immediately to the attending physician, pharmacist, and patient and/or family (as appropriate). Prepare and submit reports as required by the facility.
e. m. Check patient's Medication Administration Record (MAR) to ensure the order was accurate:
f. r. Review the five rights prior to administering medication.
i. Right Patient- You must use two identifiers:
ii. Patient picture
iii. Patient arm band
iv. (alternate) ask patient date of birth and verify with the MAR
v. Right medication
vi. Right dosage
vii. Right route
viii. Right time
g. s. Do not administer the medications if there were any questions, inconsistencies, or unclear items identified by the five rights. Any questions or inconsistencies should be clarified by consulting the physician, another nurse, a pharmacist and/or reference materials as appropriate.
h. t. Document on the MAR the following information in the appropriate column: dose, time, route (if not PO), site (if appropriate)", and initials.
i. v. Properly identify patient by checking patient armband and picture and asking the patient to state his/her name.
j. w. Double check the order if the patient questions or expresses doubts about the drug, dose, administration route or technique, etc.
k. y. Document all refused drugs on the patient's MAR. Notification of the practitioner was also to be documented in the progress note. If patient refuses the medication, circle your initials on the MAR and mark "refused".
3. PRN Medication Administration Guidelines:
a. Medication should be administered within 15 minutes of a patient's request after verification is completed that the patient was appropriate for medication. If the patient was unable to receive the medication the patient should be notified why not and when they can receive the medication.
b. One hour after administration of medication, reassess the patient and document effectiveness of medication on the PRN Effectiveness Record.
4. Labeling and Storage of Drugs
a. The pharmacist shall be responsible for proper disposal of the expired medication.
5. Medication Administration Documentation Process
a. Chart the time in the appropriate column to indicate that the medication was given.
b. All medications must be charted on the MAR immediately following administration.
c. Record and circle the scheduled time on MAR if for any reason any scheduled drug was not administered based on nursing assessment or patient refusal. Indicate the date, medication, dosage, time, reason, and nurse signature. Document physician notification in the Progress Note.

A review of the facility's "Patient Handbook" revealed that tips to promote the best experience included asking a nurse to check the patient's arm band prior to administering a medication, identifying oneself, and asking for an explanation for the reason for the medication. In addition, the patient was entitled to safe and quality care, and the facility was committed to meeting those needs.

A review of "Physician Orders" dated 2/29/24 revealed that P#1's observation status was to be monitored every 15 minutes (Q15) and given the following medications and dosages: Cephalexin (Keflex) (antibiotic to treat infections) every six hours, Phenazopyridine HCL (Urinary Pain Relief) three times a day, sertraline HCL (treatment of depression) once a day.

A review of "Medication Administration Record" dated 2/29/24 to 5/1/24 revealed on 2/29/24 at 5:14 a.m. a Registered Nurse (RN) attempted to administer Keflex and P#1 refused medication. P#1 received Ondansetron and Keflex on 2/29/24 at 12:21p.m.
Continued review revealed that P#1 received Keflex on 3/1/24 at 1:30 a.m., 3/2/24 at 6:50 a.m., 3/2/24 at 2:13 p.m. and on 3/2/24 at 12:01 a.m.

A telephone interview was conducted with Registered Nurse (RN) DD on 5/3/24 at 9:45 a.m. RN DD had worked at the facility for six months and explained that RN DD had moved to different units when it was short-staffed.
RN DD stated that medications were generally prepared in advance, and the Behavioral Health Associate (BHA) would bring the patient to the nurses' station for medication. RN DD asked the patient for their name and date of birth. In addition, RN DD could verify the patient by looking at the patient's photograph, which was available in the medical record (MR). RN DD explained that the patient had a wristband identifying the patient's name. There were times when a patient did not have a wristband because the patient had not received one, the wristband fell off, or the patient removed it. RN DD said patient-identifying wristbands were not consistently provided or worn. Only about 50 percent of the patients wore wristbands. RN DD continued to say that the patient's photographs were also not consistently entered into the patient's medical record due to short staffing. RN DD was unaware of a hospital policy addressing patient identification when administering medication.

RN DD stated she did not recall P#4. RN DD remembered an incident when a patient received another patient's medications in error. RN DD stated that this occurred when RN DD was unfamiliar with the patient and the unit was short-staffed. RN DD said she had been given a description of the patient who was to arrive for medication, and a patient arrived at the medication window. RN DD said she asked the patient their name, and the patient responded with what RN DD heard as the name that RN DD had medication ready for. RN DD called the patient's name prior to administering the medication, but the patient at the window had not corrected RN DD. RN DD administered the medication to the patient and later when the actual patient came up for their medications, RN DD realized the error.

A review of an Incident Report Form dated 1/20/24 9:05 p.m. revealed an incident involving P#4. A summary of the events revealed that P#4 presented to the medication window. When the staff asked P#4 her name, she told them a different name other than her own. No picture or patient armband was available for verification. P#4 was then administered medication for the name of the patient's name she told staff. About 45 minutes after medications had been administered, the actual patient whose name was provided by P#4 approached and the medication error was noted. P#4 did not receive her scheduled medications due to the medication error.

A review of the Nurse Progress Note dated 1/20/24 at 8:20 p.m. by RN DD revealed that P#4 approached the medication window, and when asked, P#4 stated her name was another patient name (no picture or armband). The medication under that patient's name was then pulled and given. The medications were methocarbamol (Robaxin) (muscle relaxant) 750 milligram (mg), Vistaril (antihistamine) 25 mg, quetiapine fumarate (used to treat depressive disorders) 50 mg, and gabapentin (treated nerve pain) 300mg. About 45 minutes later, a patient with the same name approached, and the medication error was noticed.