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Based on record review, policy review and staff interview, it has been determined that the hospital failed to meet the Condition of Participation: Nursing Services relative to medication administration resulting in a medication error necessitating higher level of care for Patient ID #1.

Findings are as follows:

1. The hospital failed to provide nursing care in accordance with the hospital policy for "Medication Administration" for Patient ID #1, resulting in the patient requiring cardiopulmonary resuscitation (CPR) and transfer to the Intensive Care Unit (ICU). (refer to A-0405)

Based on record review, policy review and staff interview, it has been determined that the hospital failed to follow their own policy regarding safe medication administration which resulted in a medication error necessitating higher level of care for 1 of 2 sample patients receiving care in the electrophysiology laboratory, Patient ID #1.

Findings are as follows:

The hospital's policy titled "medication administration" effective April 2022 states in part,

"I. Purpose

to describe the requirements for the timely, safe, administration and documentation of medications by individuals, such as registered nurses ...

...Definitions

Five (5) Rights of Medication Administration Practice

...Right Medication: the correct medication, to ensure that the medication being given to the patient matches that prescribed for the patient ...

Right Dose: the correct dose, to ensure that the dosage of the medication matches the prescribed dose, and that the prescription itself does not reflect an unsafe dosage level ..."

Record review revealed that Patient ID #1 presented to the hospital in January of 2023 and was directly admitted to the Critical Care Unit (CCU) for a planned pacemaker insertion (a procedure in which a device is implanted in the chest to help control the heartbeat).

Review of the patient's "Progress Notes" dated 1/10/2023 at 8:13 PM, revealed that the plan for the patient was to be watched "closely on telemetry" and "proceed with a placement of a pacer tomorrow."

The patient's "Transfer" notes dated 1/11/2023 at 7:13 PM state under a section titled, "Hospital Course" that when the patient arrived to the CCU, she/he was "alert and oriented, pleasant and cooperative and only complained of shortness of breath upon exertion. The patient was "hemodynamically stable throughout the night and early morning", and was sent to receive his/her pacemaker in the afternoon in "stable condition."

Record review of a "significant event and procedure report" dated 1/11/2023 at 7:05 PM completed by the Electrophysiology Physician, states that the patient was brought to the electrophysiology lab in stable condition with stable vital signs. Further review of this report revealed that the patient experienced "tonic clonic movement" (seizure activity) after Ancef [an antibiotic] was initiated intravenously for which Ativan (medication used to help treat seizures or anxiety) was administered and anesthesia was notified to intubate the patient.

The report further states that cardiopulmonary resuscitation (CPR) was initiated when a pulse was not identified on the patient who eventually experienced Pulseless Electrical Activity (a condition where the electrical activity of the heart is not accompanied by a palpable or effective pulse) with Accelerated Idioventricular Rhythm and intermittent asystole (a form of cardiac arrest when your heart's electrical system fails, causing your heart to stop pumping) for which CPR and rounds of epinephrine were continued. The Physician further stated in the report that a "stable pulse was regained after 25 minutes of CPR" and the following intravenous drips were initiated: dopamine (medication used to increase blood pressure in emergencies), Levophed (medication used to treat life-threatening low blood pressure), bicarbonate (medication used to help treat excess acid in the body), and Ativan.

According to the report, despite the administration of Ativan, the patient continued to seize requiring CPR "throughout the resuscitative efforts" due to "intermittent pulseless status" and a "balloon tipped TVP [transvenous cardiac pacer]" was inserted under US [ultrasound] guidance into [his/her] RIJ [right internal jugular vein]" which "had to be repositioned ...after it was dislodged during compressions."

Ultimately, a temporary pacemaker was placed on the patient and it was suspected that the medication Marcaine an anesthetic could have been administered instead of the antibiotic Ancef.

The patient was subsequently transferred to the Intensive Care Unit, intubated and ventilated.

Record review of the patient's "Plan of Care" dated 1/19/2023 at 6:05 AM revealed a care plan for "Pain Management" with a note which stated, "Continues to report Left chest/rib pain at rib fracture ..."

During a surveyor interview with the Risk Manager on 1/19/2023 following the review of the patient's "Pain Management" care plan, she confirmed that the patient's rib fracture was a result of the compressions performed during CPR on 1/11/2023 while in the electrophysiology laboratory.

During a surveyor interview on 1/18/2023 at 11:08 AM, with Employee A, Registered Nurse, she revealed that in preparation for the patient's original procedure, Marcaine, lidocaine with epinephrine [anesthetic], and Ancef were each drawn into a 30-milliliter syringes all of which had a large orange sticker and a medication label. She revealed that when she was ready to administer the Ancef, she picked up what she thought was Ancef from the tray where the medications are prepared and walked over to the patient and administered it. She stated that she read the label on the syringe while it was still sitting on the tray before she picked it up which read "Ancef 2 milligrams IV in bold, black, sharpie type lettering."She indicated that she thinks the large orange sticker flap from the Ancef syringe may have been sitting on top of the Marcaine syringe when she picked up a syringe. When asked if she checked the label on the syringe when she arrived at the patient's bedside right before administering the medication to the patient, she stated, "No" and was unable to explain why she did not look at the mediation label on the syringe prior to administering the medication to the patient.

During a surveyor interview on 1/18/2023 at 2:34 PM, with the Electrophysiology Laboratory Clinical Manager, she indicated that she expected Employee A, to look at the medication and verify what was to be given right before administering it to the patient. She indicated that although Employee A looked at the label while it was on the tray, she would have expected her to look at it again right before administering it to the patient at the bedside.