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Based on record review, hospital policy review, and staff interview, it was determined that the hospital failed to administer medications in accordance with hospital policy and the rights of medication administration practice.

Findings are as follows:

The hospital failed to ensure a nurse verified and scanned the right medication prior to it's administration to the patient. This failure resulted in a patient receiving the incorrect medication requiring an immediate intervention. On 3/29/2024, the hospital submitted an abatement plan indicating the immediate actions the hospital would take to prevent serious harm from occurring or recurring.

On 4/1/2024 an audit was completed by the state surveyors. Verification of policy review, and staff education records were verified. Interviews with staff was conducted which indicated staff had knowledge of the incident and corrective measures.

(Refer to A-0395)

Based on record review, hospital policy review, and staff interview, it was determined that the hospital failed to administer medications in accordance with hospital policy, and the Eight (8) Rights of Medication Administration Practice for 1 of 7 patients reviewed for medication administration, Patient ID #1.

Findings are as follows:

Record review for Patient ID #1 revealed a physicians order for a nicardipine drip (an intravenous (IV) medication used to treat high blood pressure). This medication was noted to have been administered by an insulin drip (an intravenous medication used to decrease elevated blood sugars) in error. This error resulted in the patient suffering a low blood sugar, then requiring the patient to receive an IV solution of Dextrose 50% and Dextrose 10% (medications used to treat low blood sugars).

Review of the hospital's policy titled, "Medication Administration, System Admin 110," last revised on 1/2024 states in part,

" ...Eight (8) Rights of Medication Administration Practice

1. Right Patient ...
2. Right Medication: the correct medication, to ensure that the medication being given to the patient matches that prescribed for the patient ...
3. Right Dose ...
4. Right Route ...
5. Right Time ...
6. Right Documentation ... document administration prior to administering the ordered medication. Barcode scanning should be utilized.
7. Right Reason ...
8. Right Response ..."

Record review revealed Patient ID #1 presented to the emergency department in March of 2024 after striking their head and sustaining a laceration following a fall. Upon arriving to the hospital, the patient was confused, and had garbled speech . Diagnostic imaging confirmed bilateral subdural hematomas (a condition due to bleeding under the membrane covering the brain). The patient underwent a left craniotomy (a surgical operation on the skull) to remove the hematoma and was subsequently admitted to the Neurosciences Critical Care Unit. The patient's medical history includes, but is not limited to, high blood pressure, low potassium, glaucoma, and a ventriculoperitoneal shunt (a surgical procedure to implant a device that relieves pressure on the brain due to excess fluid).

Review of a Significant Event Note dated 3/24/2024 revealed that the patient received approximately 35 to 45 units of regular insulin which required an IV infusion of Dextrose 50% and Dextrose 10% to reverse the effects of the insulin drip. Further review revealed that nursing staff were advised to perform finger sticks every 15 minutes for 4 hours to check blood sugar levels.

Review of a physician progress note dated 3/25/2024, confirmed that Patient ID #1 was administered Dextrose 10% as the insulin drip was administered accidentally.

During a surveyor interview with Employee A, Registered Nurse, on 4/1/2024 at 9:05 AM, she stated that when walking by Patient ID #1's room she observed that the nicardipine drip being infused into the patient was almost empty. In response to this, she stated she then retrieved a new bag of nicardipine from the nicardipine bin within the Omnicell, and quickly "hung" the new IV bag of nicardipine, without scanning because another patient was attempting to "jump out of bed" and required her immediate attention. Upon returning to Patient ID #1's room she then scanned the IV bag of medication she had just hung and was alerted that this medication was not nicardipine as was ordered. She identified that the infusion was insulin instead of nicardipine. When questioned, Employee A acknowledged she did not scan the nicardipine drip prior to administering it to Patient ID #1 and indicated she only looked at the color of the box, which is confirmed to be similar for both insulin and nicardipine.