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Based on observation, review of policy and procedure and interview, it was determined the facility failed to ensure the staff followed their policy for medication administration. This did affect Patient Identifier (PI) # 9 and had the potential to negatively affect all patients receiving care in this facility.

Findings Include:

Facility Policy: Medication Administration
Revised: 4/07

"Policy: Medications shall be stored, controlled and dispensed as required ... Medications shall be administered ... in a manner conducive to the well being and safety of the patient...

Standard IV:

Specification 1:
Medication carts will remain locked unless in use by an authorized nursing employee.

Procedure:

Essential Steps in Procedure:

C. Method:

1. Take MAR (Medication Administration Record) and medicine cart to door of patient's room.

2. Remove the medication due at the medication hour from the patient's drawer.

...7. Lock medicine cart.

...9. Administer oral medication ...

10. Give parenteral medications. ...

11. Disposed of syringe in contaminated syringe box.

12. Return to medication cart.

13. Discard soiled disposable items in waste receptacle on cart."

An observation was conducted by the surveyor on 6/7/16 at 9:20 AM with Employee Identifier (EI) # 3, Registered Nurse (RN), to perform medication administration. EI # 3 retrieved medications from the medication room and entered PI # 9's room with the rolling medication cart. EI # 3 proceeded to unlock the rolling medication cart, prepare and administer the po (by mouth) medications and IV (intravenous) medications (Protonix and Potassium). EI # 3 did not leave the medication cart at the patient's door as directed per the facility policy.

During the medication administration PI # 9 complained of pain. EI # 3 proceeded to the medication room to retrieve IV Morphine for pain. EI # 3 left the rolling medication cart unlocked and unattended in PI 9's room twice during this process.

After administering all medications, EI # 3 then discarded all syringes and disposable items in the medication drawer of the medication cart and left the room. EI # 3 did not dispose of the syringes in the sharps container and the disposable items in the waste receptacle as directed per the facility policy.

An interview was conducted on 6/7/16 at 9:55 AM with EI # 2, Nurse Manager, who verified the staff did not follow the facility policy for medication administration.

Based on observation, review of policy and procedure and interview, it was determined the facility failed to ensure the staff followed their policy for medication administration. This did affect Patient Identifier (PI) # 9 and had the potential to negatively affect all patients receiving care in this facility.

Findings Include:

Facility Policy: Medication Administration
Revised: 4/07

"Policy: Medications shall be stored, controlled and dispensed as required ... Medications shall be administered ... in a manner conducive to the well being and safety of the patient...

Standard IV:

Specification 1:
Medication carts will remain locked unless in use by an authorized nursing employee.

Procedure:

Essential Steps in Procedure:

C. Method:

1. Take MAR (Medication Administration Record) and medicine cart to door of patient's room.

2. Remove the medication due at the medication hour from the patient's drawer.

...7. Lock medicine cart.

...9. Administer oral medication ...

10. Give parenteral medications. ...

11. Disposed of syringe in contaminated syringe box.

12. Return to medication cart.

13. Discard soiled disposable items in waste receptacle on cart."

An observation was conducted by the surveyor on 6/7/16 at 9:20 AM with Employee Identifier (EI) # 3, Registered Nurse (RN), to perform medication administration. EI # 3 retrieved medications from the medication room and entered PI # 9's room with the rolling medication cart. EI # 3 proceeded to unlock the rolling medication cart, prepare and administer the po (by mouth) medications and IV (intravenous) medications (Protonix and Potassium). EI # 3 did not leave the medication cart at the patient's door as directed per the facility policy.

During the medication administration PI # 9 complained of pain. EI # 3 proceeded to the medication room to retrieve IV Morphine for pain. EI # 3 left the rolling medication cart unlocked and unattended in PI 9's room twice during this process.

After administering all medications, EI # 3 then discarded all syringes and disposable items in the medication drawer of the medication cart and left the room. EI # 3 did not dispose of the syringes in the sharps container and the disposable items in the waste receptacle as directed per the facility policy.

An interview was conducted on 6/7/16 at 9:55 AM with EI # 2, Nurse Manager, who verified the staff did not follow the facility policy for medication administration.