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Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined that medication orders were not administered in accordance with the approved policies and procedures for (MR1).

Findings include:

On February 16, 2022, review of facility policy Medication Administration effective April 30, 2021, revealed "Procedure-The following practices will govern medication administration throughout this institution: The individual administering the medication will verify the medication selected for administration is the correct medication based on the medication order and the medication product label. The individual administering a medication will be aware of the following information concerning each medication before administration:
Route and frequency of administration".

On February 16, 2022, review of MR1 Medication Administration Record revealed order entered by EMP5 on January 12, 2022, noted Diazoxide 75 mg oral BID (twice a day). Further review of MR1 revealed progress note on January 16, 2022, entered by EMP 6 at 0911 noted, "Rapid response note: Rapid response called for altered mental status and hypotension. I arrived to find the patient unresponsive to painful stimuli. Pupils were dilated bilaterally and reactive to light. BP was 90s/70s with IVF infusing. Labs from earlier today were unremarkable. After several minutes the patient began to wake up. Patient explained that after the administration of medications through Peripherally Inserted Central Catheter (PICC) patient immediately felt 'pain all over' and recalls nothing after that. Review of the medications shows that diazoxide was an oral solution that should have been administered through PEG tube. Nursing confirms that it was accidentally given through PICC. This medication is a vasoconstrictor which explains the hypotension."
During interview with EMP6 on February 16, 2022, EMP6 confirmed that on January 16, 2022, during medication administration EMP6 inserted the oral medications into the PICC line accidentally. EMP6 stated that EMP6 had given the same medication in the patient's J-tube on February 15, 2022, and was aware of it's ordered route, but somehow confused it on January 16, 2022.