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Based on medical record and policy and procedure review and staff interview, nursing staff did not administer medication in accordance with accepted standards of practice for Patient #1.

Findings include:

Review on 3/14/2014, of Patient # 1 ' s medical record dated 03/02/2014 did not reveal an order for a GI Cocktail. (viscous lidocaine, donnatal, and mylanta) for this patient.

Review of the facility ' s " Medication Ordering and Administration " policy #020.0200, dated 2/2011, indicates that when administering a medication the nurse must correctly identify the patient as the one for whom the medication was ordered by using at least two hospital identifiers. The nurse must also verify that the medication selected for administration is the correct medication based on the medication order and the product label.

Telephone interview, on 04/15/2014 with Staff #6, revealed that Staff #6 mixed the medication per the order and delivered it to room #8. Staff # 6 called the patient by the name on the order and Patient #1 responded. Staff # 6 then handed Patient #1 the medication and observed the Patient drinking it. After leaving the room, Staff # 6 realized the medication was for the patient in room #9 and immediately reported the error to the Emergency Room physician, the Emergency Room Director and entered it into the hospital ' s internal reporting system.