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Based on clinical record reviews, observations, review of facility documentation and interviews for one of three sampled patients (Patient #5) who were reviewed for medication administration, the facility failed to ensure a medication was administered as directed by the physician. The findings include:

Patient #5 was admitted to the hospital on 4/17/2020 for treatment/stabilization after setting fire to his/her apartment. The Patient's diagnoses included chronic paranoid Schizophrenia, uncontrolled diabetes, and aggressive behavior.

Physician's orders dated 7/13/2020 directed the Administration of Haldol Decanoate 100 mg Intramuscular (IM), every 28 days for auditory hallucinations.

Shift notes dated 8/21/2020 identified at 5:55 PM Patient #5 punched a peer and was threatening, agitated and posturing with staff. Oral medication for agitation was administered and observations of the Patient were increased.

A Physician Evaluation Progress note dated 8/24/2020 at 9:30 AM identified Patient #5 remained verbally aggressive, disorganized, delusional, and hostile. A physician's order was obtained that directed the increase of Haldol Decanoate from 100 mg IM, every 28 days to 150 mg IM every 28 days. The increased dose was to be administered on 9/3/2020.

The Medication Administration Record (MAR) for 9/2020 identified that although Haldol Decanoate was increased on 8/24/20 to 150 mg IM, a lower dose of 100 mg was administered on 9/3/2020 at 11:00 AM.

A Non-Critical Incident Report dated 9/18/2020 identified at 10:15 AM Patient #5 threatened MD #1 and other staff members when approached for medication administration. The patient punched and kicked MD#1 and two other staff members resulting in the initiation of restraints and IM medication.

A Medication Variance Report dated 9/19/2020 identified at 5:00 AM a medication error was discovered. The report noted that a medication was incorrectly transcribed onto the MAR that resulted in the patient receiving the wrong dose of medication. The report indicated that the error did not result in any adverse consequences to the patient.

The physician was notified and directed the administration on Haldol Decanoate 50 MG

Interview, review of the clinical record and hospital documentation on 11/10/20 at 11:00 AM with Director of Nurses #1 (DNS #1) identified that on 9/3/2020 Patient #5 should have received Haldol Decanoate 150 mg, not 100 mg. The error was not discovered until the 9/19/20, 16 days later. Additionally, the DNS indicated that the night shift nurses are responsible for ensuring that all medication orders are accurately transcribed onto the new monthly MAR when it replaces the previous months MAR.

Interview and review of the clinical record on 11/16/20 at 12:30 PM with MD #2, a hospital psychiatrist identified that Haldol Decanoate is a medication that is started at a low dose and increased based on the effect it has on the patient. The most effective dose for Patient #5 had not been identified and therefore small increases in the dosage was implemented. Additionally, MD #2 indicated that it was not likely that the medication error resulted in the incident on 9/18/20.

The hospital failed to ensure the change in the dosage of a medication was accurately transcribed onto the upcoming monthly MAR resulting in a medication error of omission.

Interview on 11/16/20 at 1:00 PM with the Manager of Quality and Compliance identified that although there is not a written policy regarding the transcribing of medication, the hospital's practice is that the shift nurses are responsible for ensuring that all medication orders are accurately transcribed onto the new monthly MAR when it replaces the previous months MAR.