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Based on observation, staff interviews, and facility policy review, the facility failed to ensure a patient's right to personal privacy for one patient (P) (P#4) of four patients reviewed for patient rights. The failure resulted in a patient's medical information being revealed to other patients and staff.


Findings included:


A facility policy titled "Patient Rights," reviewed 01/2025, indicated "6. Patient Rights include the following rights" and "d. to care and treatment that is respectful, recognizes a person's dignity, cultural value and religious beliefs, and provides for personal privacy to the extent possible during course of treatment."


On 01/13/2025 at 10:29 a.m., Registered Nurse (RN) #3 was observed administering medication to P#4. The observation revealed that, when RN #3 could not find P#4's blood sugar result, RN #3 spoke loudly from a medication room to RN #4 at the nurses' station and asked for P#4's blood sugar result. The observation revealed patients were in the hall and standing next to P#4. The observation revealed RN #4 responded with P#4's blood sugar result. It was observed that RN #3 then gathered supplies and administered insulin to P#4.


On 01/13/2025 at 10:35 a.m., RN #3 stated they did not normally ask for patient information when others were around, noting they did not know why they did that.


On 01/15/2025 at 8:50 a.m., the Assistant Chief Nursing Officer stated patient privacy was important, noting they expected staff to keep patient information confidential.

Based on staff interviews, record review, and facility policy review, the facility failed to ensure medications were administered per the providers orders for one patient (P) (P#1) of four patients reviewed for medication errors. The failure resulted in a patient receiving a medication earlier than ordered with the potential for a negative impact on the medication's intended therapeutic use.


Findings included:


A facility policy titled, "The Role of Nursing in Medication Administration," revised 07/2023, in the section, "b. Medications eligible for scheduled dosing times," revealed, "(ii) There are two types of 'eligible' medications (time-critical and non-time-critical).
- Time-Critical (eligible) medications are medications which the early or late administration greater than 30 minutes might cause harm or have a significant negative impact on intended therapeutic or pharmacological effect. Time-critical medications must be administered 30 minutes before or after their scheduled dosing time, for a total window that does not exceed 1 hour. Time critical medications will include Insulin, Levothyroxine, and Warfarin.
-Non-time-critical (eligible) medications are those that a longer or shorter interval time since the prior dose does not significantly impact or change the therapeutic effect.
-All medications in the non-time critical category shall be administered within 1 hour before or after the scheduled dosing time, for a window that does not exceed 2 hours."


P#1's "Physician Medication Orders," for the timeframe from 05/23/2024 through 05/28/2024, contained an order for Haldol (haloperidol, an antipsychotic) 5 mg (milligrams) intramuscularly (IM, injected in the muscle) every four hours (Q4H) as needed (pro re nata, PRN).


P#1's "Physician Medication Orders" contained an order, started 05/23/2024, for Ativan (lorazepam, a benzodiazepine) 2 mg IM Q4H PRN.


P#1's "Physician Medication Orders" contained an order, started 05/23/2024, for diphenhydramine (Benadryl, an antihistamine) 50 mg IM Q4H PRN for extrapyramidal symptoms (EPS, movement disorder) for side effects prevention.


A "Medication Administration Record [MAR]" dated for the timeframe from 05/22/2024 through 06/12/2024 revealed P#1 could receive IM Haldol Q4H PRN. The MAR indicated Haldol was administered intramuscularly to P#1 on 05/24/2024 at 5:08 a.m. The MAR indicated another dose of Haldol was administered intramuscularly to P#1 on 05/24/2024 at 8:00 a.m., by Registered Nurse (RN) #2. The MAR documentation indicated that the two doses of Haldol were administered within two hours and 52 minutes (less than four hours apart).
A MAR dated for the timeframe from 05/22/2024 through 06/12/2024 revealed P#1 could receive intramuscular Ativan every four hours as needed. The MAR indicated lorazepam was administered on 05/24/2024 at 5:07 a.m. The MAR indicated another dose of lorazepam was administered on 05/24/2024 at 8:00 a.m., by RN #2. The MAR indicated the doses of lorazepam were administered within two hours and 53 minutes (less than four hours apart).


A MAR dated for the timeframe from 05/22/2024 through 06/12/2024 revealed P#1 could receive intramuscular Benadryl IM Q4H PRN for EPS prevention. The MAR indicated Benadryl was administered on 05/24/2024 at 5:09 a.m. The MAR indicated another dose of Benadryl was administered on 05/24/2024 at 8:00 a.m., by RN #2. The MAR indicated the doses of Benadryl were administered within two hours and 51 minutes (less than four hours apart).


On 01/14/2025 at 11:15 a.m., Medical Doctor (MD) #1 stated that Haldol, Ativan, and Benadryl were time critical medications, and they expected nurses to administer medications per orders or communicate if medications needed to be given earlier than ordered.


On 01/14/2025 at 11:52 a.m., Registered Nurse (RN) #2 stated they considered Haldol, Ativan, and Benadryl time sensitive medications, noting they generally administered these medications within an hour of the ordered time. RN #2 stated they tried to administer these medications within 30 minutes of the ordered time and, in the case of P#1, did not remember why the medications were given early.


On 01/14/2025 at 4:03 p.m., the Assistant Chief Nursing Officer (ACNO) stated they expected their staff to administer medications in a timely manner, described as between 30 minutes to an hour before or after ordered. The ACNO stated the expectation was for staff to follow orders and to get clarification when needed. The ACNO stated if a medication was ordered for every four hours, but was given at two hours and 52 minutes, it would have to be investigated.