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Based on policy review, medical record review, document review and interview, the hospital failed to ensure Nursing Services provided care and services to meet patient needs when they failed to ensure nursing staff (Nurse #1) followed hospital policy and procedures and physician orders for medication administration for 2 of 4 (Patient #1 and 2) sampled patients, followed physician orders for cardiac laboratory testing and electrocardiogram for 1 of 4 (Patient #3) sampled patients, and followed physician orders for procedures to stimulate bowel movements for 1 of 4 (Patient #4) sampled patients. Nursing Services failed to ensure the medication error for Patient #1 was identified and investigated timely.

The findings included:

1. Review of the Hospital #1 policy "Medication Administration for Pharmacy and Nursing" last revised 3/29/2022, revealed, "...The purpose of this medication administration policy and procedure is to guide the practice of licensed /credentialed staff in the safe administration of medications...Identification of Patients prior to Administering Medication...Prior to administration: Launch electronic medical record at the patient's bedside. Confirm correct patient by scanning the armband...Medication Administration...B. Prior to medication administration, the licensed/credentialed staff will: 1. Review [physician] orders...C. Licensed/credentialed staff completes the five rights prior to administering the medication: right drug, right dose, right route, right patient and right time...D. All medications are scanned and discern alerts addressed prior to the administration...E. Staff member who completes the above steps in regards to the medication(s) will administer the medication(s)... Maintenance of NCS [Narcotic Controlled Substances] in the ADM [Automatic Dispensing Machine]: 1. Each time the drawer is accessed the nurse will inventory the medications. 2. All NCS are inventoried every shift...Discrepancies are investigated and reported to the Charge Nurse/Nurse Manager as soon as discovered....All discrepancies should be resolved prior to the end of the shift. Do not leave unresolved discrepancies for the following shift ...Medication Error/ Near Miss Guidelines A medication error is defined as any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in control of the health care professional...Such events may be related to professional practice, health care products, procedures, and systems including: prescribing; order communication; product labeling; packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring and use. Medication errors are included in one of the following categories: omission error, wrong patient, wrong dose, wrong route...Reporting: The goal of reporting medication orders is to identify and document the cause of the error in order to develop systems that minimize recurrence. The problems and sources of medication errors are multidisciplinary and multifactorial. Healthcare professionals involved in the prescribing, administering, or monitoring of medications are made aware of medication errors. Reporting Procedure: Whoever discovers the error/near miss will complete a medication variance found on the Intranet [internal hospital system for forms/polices]...This report is NOT part of the medical record and is protected information as part of [named Hospital] Performance Improvement Program. The person completing the Referral does not have to include their name. Medication errors/near miss with potential harm to the patient are reported to the patient's physician and nurse immediately. The Director of Pharmacy is also notified...Medications Brought From Home By Patient (Own Supply) [named Hospital #1] discourages the use of the patients own supply of home medications because this practice bypasses many of [named Hospital #1] medication safety efforts; however, in certain controlled situation, patients may take their own supply of homw [home] medications if ordered by the attending physician and after appropriate identification by the pharmacy...In the event the pharmacy does not stock the a medication...and there is no suitable formulary alternative, it may be necessary to use the patients own medication. Pharmacy will contact the nurse to see if the medication is with the patient. Nurse will bring the home medication. Pharmacy will identify patient's own medication before patient use...If deemed acceptable for use, the pharmacist will enter the medication using the "home med" function in the computer system so that the medications will appear on the electronic medication record and generate a barcoded label. 'Patient's own supply' medication will be stored in its original labeled container in the ADM under "medications not loaded" in the patients designated medication bin. Nurse will dispense "patient's own supply" medication from ADM, scan the patient and medication upon administration, which is documented on the electronic medical record ..."

Review of the Hospital #1 policy "Processing Physician Orders" last revised 6/29/2021, revealed, "This policy is a guideline for processing and/or transcribing physician orders...Clarification of Orders If a physician order needs clarification, the duly authorized personnel will contact the physician and document physician clarification. Whenever nursing staff is unfamiliar with or questions an order, the following steps should be taken: Consult pharmacist for medication orders, Contact MD [Medical Doctor] who entered the order, if after completing steps [referenced above] the nurse still has questions about the order, contact immediate supervisor for assistance. Medication Orders Licensed staff will review the medication in the electronic medical record and acknowledge the five rights: Right patient, Right drug, Right route, Right dose, Right time..."

Review of the Hospital #1 policy "Haloperidol Parenteral Therapy (Haldol)" revised 5/17/2019, revealed, "...the Food and Drug Administration (FDA) strengthened warnings regarding the use haloperidol due to numerous reports of QT prolongation [extended interval between the heart contracting and relaxing] and Torsades de Pointes [a life threatening heart rhythm disturbance] when administered via the intravenous route ...The use of intravenous haloperidol is limited [Named Hospital #1]...the intravenous route of administration may be used in certain clinical situations...Critical Care...Anesthesia...Emergency Department...torsade de pointes has been reported with single intravenous haloperidol dose...Monitoring of the patient will be consistent with critical care guidelines...continuous cardiac monitoring...Vital signs...hourly at minimum...Blood Pressure...within 15 minutes of administration of the haloperidol..."

2. Medical record review revealed Patient #1 was a 41-year-old male admitted to the Intensive Care Unit at Hospital #1 from Hospital #2 on 7/2/2023 for Pulmonary Services. Patient #1 required intubation but was later extubated and transferred to the Floor 1 Cardiac/Medical unit. Patient #1 required seizure medications that were non-formulary and required the use of his home pre-packaged pharmacy medications for clobazam (controlled medication used to treat seizures) and Xcopri (medication used to treat partial-onset seizures (also called focal seizures) in adults). On 7/17/2023, Nurse #1 administered 22.5 tablets (225 milligrams (mg)) of the clobazam instead of the physician ordered 1.5 tablets (15 mg) of clobazam. The medication error was not discovered until 7/18/2023, because the Charge Nurses failed to complete and document the narcotic count on the morning of 7/18/2023.

3. Medical record review revealed Patient #2 was a 93-year-old female who was transported from a nursing facility to Hospital #1's Emergency Department (ED) on 8/13/2023 for respiratory distress, with a history of Alzheimer's dementia, hypertension and tachycardia. Patient #2 was admitted to Hospital #1 on 8/13/2023 to the Floor 1 Cardiac/Medical unit. Patient #2 had physician orders for Haldol (antipsychotic medication used to treat certain types of mental disorders) 0.4 milliliters (ml) intramuscular for agitation. On 8/13/2023 at 2:55 PM, Nurse #1 administered 0.8 ml of Haldol intravenously (twice the ordered amount and incorrect route).

4. Medical record review revealed Patient #3 was a 73-year-old female who was transferred to Hospital #1 on 7/28/2023 for shortness of breath, swelling and elevated troponin (protein that's released in the bloodstream during a heart attack). Patient #3 was admitted to Hospital #1 to the Floor 1 Cardiac/Medical unit. Patient #3 had physician orders for troponin laboratory and Electrocardiogram (EKG) to be completed every 3 hours. Nurse #1 interpreted Physician #3's "no new orders" as discontinue the troponin and EKG and failed to complete the troponin labs and EKG timely.

5. Medical record review revealed Patient #4 was a 64-year-old female who presented to Hospital #1's ED on 7/17/2023 with loss of consciousness and chest pain. Patient #4 was admitted to the Floor 1 Cardiac/Medical unit for further evaluation and treatment. Patient #4 had been previously scheduled for an outpatient colonoscopy on 7/22/2023, which was completed during her inpatient hospitalization. A Nurse Practitioner ordered tap water enemas until bowel movements clear on 7/22/2023. Nurse #1 failed to perform the tap water enemas as ordered prior to Patient #4's scheduled colonoscopy.

6. Review of the personnel file for Nurse #1 revealed a hire date of 4/4/2022 as a Registered Nurse (RN). Review of a memorandum of agreement dated 6/21/2023 revealed Nurse #1 would work 5 (five) 12-hour night shifts each week.

Review of Nurse #1's electronic timesheet, provided by Nurse #2, revealed after the medication error resulting in Patient #1 being administered 22.5 tablets of clobazam, Nurse #1 worked 9 (nine) 12 hour night shifts (7/18/2023, 7/19/2023, 7/20/2023, 7/21/2023, 7/24/2023, 7/25/2023, 7/26/2023, 7/27/2023, 7/28/2023) and 1 (one) 12 hour day shift (7/30/2023) before she received education and retraining by the Nurse Educator on 8/2/2023 and 8/4/2023.

Nurse #1 was terminated on 8/15/2023 after the Haldol medication error for Patient #2.

Refer to A 392 and A 405

Based on policy review, medical record review, document review and interview, the hospital failed to ensure nursing staff (Nurse #1) followed physician orders for cardiac laboratory testing, electrocardiogram and procedures to stimulate bowel movements for 2 of 4 (Patient #3 and 4) sampled patients.

The findings included:

1. Review of the Hospital #1 policy "Processing Physician Orders" last revised 6/29/2021, revealed, "This policy is a guideline for processing and/or transcribing physician orders...Clarification of Orders If a physician order needs clarification, the duly authorized personnel will contact the physician and document physician clarification. Whenever nursing staff is unfamiliar with or questions an order, the following steps should be taken: Consult pharmacist for medication orders, Contact MD [Medical Doctor] who entered the order, if after completing steps [referenced above] the nurse still has questions about the order, contact immediate supervisor for assistance..."

2. Medical record review for Patient #3 revealed a 73-year-old female who was transferred from Hospital #2's Emergency Department (ED) to Hospital #1's ED on 7/28/2023 for shortness of breath and swelling and was found to have an elevated Troponin (protein that is released in the bloodstream when heart muscle is damaged). Upon arrival, Patient #3 was admitted to Hospital #1.

Patient #3's "History and Physical Report" at Hospital #1, dated 7/28/2023 at 22:15 (10:15 PM) and signed by Physician #3, revealed Patient #3's past medical history listed diagnoses including Anxiety, Hypertension, Type 2 Diabetes, Obesity, Hypertension and Hyperlipidemia. Patient #3 reported she felt bloated from her neck to her stomach for the last 3 days and thought she was having an anxiety attack. Patient #3 denied chest pain.

Review of the Troponin High Sensitivity Level for Patient #3 performed at Hospial #2 (prior Patient #3's arrival at Hospital #1) revealed a high level of 87 and a high repeat level of 83 (normal range for Troponin High Sensitivity was 4-60 picograms/milliliter), The electrocardiogram (EKG) was concerning for ST elevation (total blockage of the coronary artery). Cardiology was consulted (at Hospital #2), and Cardiology did not believe Patient #3 had a STEMI (ST elevation myocardial infarction - heart attack) and recommended Patient #3 start on a heparin drip and transferred to Hospital #1 for further evaluation.

Patient #3's physical exam performed at Hospital #1 revealed no acute distress. The Assessment/Plan at Hospital #1 revealed Patient #3 was diagnosed with atypical chest pain and interventions to continue aspirin, start a statin medication (medication to lower cholesterol), trend troponins and EKGs, consult cardiology, and continue the heparin drip.

A physician's order dated 7/28/2023 at 21:40 (9:40 PM) revealed, "...Troponin T [part of the troponin complex, which are proteins integral to the contraction of skeletal and heart muscles]....q [every] 3h [hours], for 3...times...EKG q3h...3...times..."

Review of Patient #3's Troponin T levels dated 7/28/2023 revealed at 10:00 PM, the level was 36.2, on 7/29/2023 at 1:24 AM, the level was 36.8 (normal reference range 0.0-13.9 nanograms/milliliter). Nurse #1 documented "Critical Results Notification" on 7/28/2023 at 10:15 PM revealed "...[Physician #3] ...Time of Secure Message ...7/29/2023 22:15 [10:15 PM]...Critical Result Notification Comment...no new order..."

Review of Patient #3's EKG's revealed the first EKG was done on 7/28/2023 11:04 PM, the second EKG was done on 7/29/2023 at 12:33 AM, and the third one was done at 4:30 AM (third EKG completed by Nurse #1 one hour later than the Physican ordered).

Review of a Physician order signature dated 7/29/2023 at 3:51 AM, revealed Patient #3 " ...Troponin T ...Discontinue ...Entered and electronically signed by [Nurse #1] ...Phone with Read Back order by [Physician #3] ...Order Status Discontinued ...7/29/2023 3:50 ....Cosignature Routed to [Physician #3] ...Refused by ...[Physician #3] on 7/29/2023 at 6:28 ...Refusal comment ...DID NOT GIVE THIS ORDER ..."

In an interview on 2/6/2024 at 10:03 AM, Nurse #2 was asked if the third EKG and Troponin T were done on Patient #3. Nurse #2 confirmed Nurse #1 received an order for "No new orders" from Physician #3 and Nurse #1 canceled the orders. Nurse #2 stated, "Yes... should be done...the EKG was Nurse #1 responsibility...It was due at 3:33 AM [on 7/29/2023]...The Troponin was labs responsibility to draw..."

In an interview on 2/6/2024 at 2:50 PM, the Nurse Educator stated she had been a clinical educator for 8 years. The Nurse Educator stated she was asked to conduct education for Nurse #1 by Nurse #2, after Nurse #1's medication error on 7/17/2023 (Nurse #1 administered 22.5 tablets of clobazam (controlled medication used to treat seizures) to Patient #1 instead of 1.5 tablets as ordered by the physician). The Nurse Educator stated she did the teaching/education for Nurse #1 on 8/2/2023. The Nurse Educator stated on 8/4/2023, 2 days after the re-education of Nurse #1, she was again notified by Nurse #2 to meet with Nurse #1 regarding a teachable moment where she failed to call critical lab results for Patient #3 (Nurse #1 called Physician #3 with the lab results but misunderstood Physician #3 who told Nurse #1, "no new orders," and Nurse #1 cancelled the orders for the Troponin lab and EKG). The Nurse Educator stated she met with Nurse #1 again on 8/4/2023. The Nurse Educator stated she provided education on clear communication with the physicians and to use the read back method anytime you are getting physician orders.

In an interview on 2/7/2024 at 11:00 AM, the Lab Analyst confirmed Patient #3's order had been canceled for the Troponin lab that was due at 3:50 AM (on 7/29/2023).

In a telephone interview on 2/8/2024 at 8:55 AM, Physician #3 confirmed she was working the night of 7/28/2023 and recalled Nurse #1 had notified Physician #3 of critical labs. Physician #3 verified she gave orders for "No new orders." Physician #3 stated, "The computer triggered me the orders had been discontinued around 6:00 AM [on 7/29/2023]...I called [named Nurse #5]...[named Nurse #1] had told [named Nurse #5] she had cancelled the orders for the 3rd Troponin and EKG..." Physician #3 confirmed she did not give an order to cancel the EKG and Troponin. Physician #3 stated, "...common to give an order for no new orders...it does not mean to cancel the orders..." When asked if she had any other concerns with Nurse #1, Physician #3 stated, "...I made sure anyone that was sick did not have her..." Physician #3 stated this concern was related to Nurse #1 administering 22.5 tablets (225 milligrams) of clobazam rather than 1.5 tablets (15 milligrams) on 7/17/2023 at 9:19 PM as ordered.

In a telephone interview on 2/13/2024 at 12:20 PM, Nurse #1 confirmed after notifying the Physician #3 of Patient #3's Troponin results, she received an order for "No new orders." Nurse #1 stated she had never received or had a doctor to say, "No new orders." Nurse #1 confirmed she interpreted "No new orders" as do no further and canceled the Troponin.

3. Medical record review for Patient #4 revealed a 64 year old female who presented to Hospital #1's ED on 7/17/2023 with loss of consciousness and chest pain. An EKG indicated Patient #4 was tachycardic (a heart rate over 100 beats a minute). Patient #4 was administered breathing treatments in the ED for wheezing due to her history of Chronic Obstructive Pulmonary Disease.

Review of a hospitalist progress note dated 7/20/2023 revealed, "...Recently being evaluated for iron deficiency anemia and was referred for colonoscopy which has yet to happen..."

Laboratory results revealed Patient #4's D dimer was elevated (D-dimer is normally undetectable or only detectable at a very low level unless your body is forming and breaking down significant blood clots), and the patient had a history of venous thromboembolic disease (condition when blood clots form in veins). Patient #4 was admitted to Hospital #1 for further evaluation and treatment. Patient #4 had been previously scheduled for an outpatient colonoscopy on 7/22/2023, prior to her hospitalization, so the colonoscopy (a procedure in which a flexible fiber-optic instrument is inserted through the anus in order to examine the colon) and esophagogastroduodenoscopy (EGD - simple procedure to examine your upper gastrointestinal tract) were conducted on 7/22/2023.

Review of a nurse practitioner order dated 7/22/2023 at 5:07 AM, revealed, "tap water enemas til [until] clear..."

Review of a hospitalist progress noted dated 7/22/2023 revealed, "...In the am [morning] required tap water enemas to complete her colon prep. Awaiting EGD and colonoscopy..."

Review of the medical record revealed there was no tap water enemas documented on 7/22/2023 by Nurse #1.

In an interview on 2/6/2024 at 9:43 AM, Nurse #2 verified she had been notified by the Charge Nurse (Nurse #5) that Nurse #1 had failed to complete orders for enemas for Patient #4. Nurse #2 stated a Nurse Practitioner ordered tap water enemas for Patient #4 on 7/22/2023 at 5:07 AM, and the order was verified by Nurse #5 on 7/22/2023 at 5:20 AM. Nurse #2 stated it would have been the responsibility of the night shift nurse assigned to Patient #4 (Nurse #1) to initiate the enemas, because night shift took the order and the shift did not end until 7:00 AM. Nurse #2 verified there were no enemas documented on 7/22/2023.

In a telephone interview on 2/6/2024 at 12:30 PM, Nurse #5 verified she worked as a Charge Nurse and had supervised Nurse #1 at times. When asked about Patient #4, Nurse #5 stated Patient #4 was scheduled for a colonoscopy on 7/22/2023 and had an order for an oral liquid colon preparation (prep). Nurse #5 stated during the night shift a patient care technician reported Patient #4 had been refusing to take the oral colon prep and was concerned she would not have good results for the procedure scheduled on 7/22/2023. Nurse #5 stated she contacted a Nurse Practitioner and obtained an order for tap water enemas until the bowel was clear. Nurse #5 stated she informed Nurse #1 of the orders and instructed her to complete the tap water enemas for Patient #4. Nurse #5 stated she asked Nurse #1 if she needed any help and Nurse #1 indicated she did not need help. Nurse #5 stated Nurse #1 did not perform the tap water enemas as ordered for Patient #4. Nurse #5 stated when she later asked Nurse #1 about the failure to perform the enemas, Nurse #1 seemed surprised that so much time had passed, and Nurse #1 stated she had been completing other nursing duties and failed to get the enemas for Patient #4.

In a telephone interview on 2/13/2024 12:20 PM, Nurse #1 verified she had taken care of Patient #4 when she was hospitalized in July 2023. Nurse #1 stated she did not perform the tap water enema because she had to find a bag for the enema. Nurse #1 stated Nurse #5 found a bag for her, but when she approached Patient #4 at around 6:30 AM to perform the enema, Patient #4 stated to hold off on the enema because she needed to have a bowel movement. Nurse #1 stated she assisted Patient #4 to the toilet and left the room with instructions for Patient #4 to call when she was finished. Nurse #1 stated Patient #4 had a large bowel movement and Nurse #1 reported to the oncoming nurse at shift change that she was unable to carry out the enema. Nurse #1 stated, "...my shift was done at 7 [7:00 AM]. I can't stay over to give an enema ma'am." Nurse #1 stated she was unable to recall the name of the nurse she transitioned the enema to at the end of her shift.

In an interview on 2/13/2024 at 3:00 PM, the Director of Quality and Risk Management stated Nurse #10 was the nurse who assumed care for Patient #4 after Nurse #1 went off shift on 7/22/2023. The Director of Quality and Risk Management stated Nurse #10 was on Family Medical Leave Act and was not available for interview during the complaint investigation.

4. Review of the personnel file for Nurse #1 revealed a hire date of 4/4/2022 as a Registered Nurse (RN). Review of a memorandum of agreement dated 6/21/2023 revealed Nurse #1 would work 5 (five) 12-hour night shifts each week during the period of 6/25/2023- 7/22/2023.

Review of a document titled "One on One Training-Medication Administration" dated 8/4/2023, revealed, the Nurse Educator documented, a "...teachable moment..." with Nurse #1. The Nurse Educator documented "What was Taught: If you call the provider for a critical and they say 'no new orders', this means that the provider does not have any new orders related to this result at this time and we still must carry out previous standing orders. When...the provider...state 'no new orders' we can ask for clarification...When the provider is giving an order in person or over the phone, the nurse should repeat the order back to the provider. This ensure the correct order is placed and is an expectation for safety and ensure, proper, clear communication...Understanding to give an enema until the bowel movement is clear if that is the order..." This education was conducted 6 days after Patient #3's Troponin and EKG orders were not followed and 13 after Patient #4's enema orders were not followed.

Review of a Corrective Action document for Nurse #1 dated 8/14/2023 at 12:00 AM, revealed Nurse #2 documented the Corrective Action for Nurse #1's error for Patient #3 for 16 days after Patient #3's Troponin labs were discontinued, and error for Patient #4 23 days after Patient #4's physician orders for enemas were not followed. The document revealed, "Did not admin [administer] tap water enemas til [until] clear nor did she notify MD [physician] that orders not done. Thought 'no new orders' meant to stop doing TPI [Troponin] and EKGs. EKGs done late and results not reported timely." The "Desired Behavior" was documented as "follow all MD orders or notify provider. No new orders does not mean cancel existing orders. Report critical EKGs timely."

Refer to A 405

Based on policy review, medical record review, document review and interview, the hospital failed to ensure nursing staff (Nurse #1) followed hospital policy and procedures and followed written physician orders for medication administration for 2 of 4 (Patient #1 and 2) sampled patients. The hospital failed to identify the medication error timely for Patient #1 due to nursing staff failure to complete narcotic/controlled substance counts timely according to hospital policy, and Nurse #1 worked 10 additonal 12 hour shifts after the medication error for Patient #1 occurred.

The findings included:

1. Review of the Hospital #1 policy "Medication Administration for Pharmacy and Nursing" last revised 3/29/2022, revealed, "...The purpose of this medication administration policy and procedure is to guide the practice of licensed /credentialed staff in the safe administration of medications...Identification of Patients prior to Administering Medication...Prior to administration: Launch electronic medical record at the patient's bedside. Confirm correct patient by scanning the armband...Medication Administration...B. Prior to medication administration, the licensed/credentialed staff will: 1. Review [physician] orders...C. Licensed/credentialed staff completes the five rights prior to administering the medication: right drug, right dose, right route, right patient and right time...D. All medications are scanned and discern alerts addressed prior to the administration ...E. Staff member who completes the above steps in regards to the medication(s) will administer the medication(s)... Maintenance of NCS [Narcotic Controlled Substances] in the ADM [Automatic Dispensing Machine]: 1. Each time the drawer is accessed the nurse will inventory the medications. 2. All NCS are inventoried every shift...Discrepancies are investigated and reported to the Charge Nurse/Nurse Manager as soon as discovered....All discrepancies should be resolved prior to the end of the shift. Do not leave unresolved discrepancies for the following shift...Medication Error/ Near Miss Guidelines A medication error is defined as any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in control of the health care professional...Such events may be related to professional practice, health care products, procedures, and systems including: prescribing; order communication; product labeling; packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring and use. Medication errors are included in one of the following categories: omission error, wrong patient, wrong dose, wrong route...Reporting: The goal of reporting medication orders is to identify and document the cause of the error in order to develop systems that minimize recurrence. The problems and sources of medication errors are multidisciplinary and multifactorial. Healthcare professionals involved in the prescribing, administering, or monitoring of medications are made aware of medication errors. Reporting Procedure: Whoever discovers the error/near miss will complete a medication variance found on the Intranet [internal hospital system for forms/polices]...This report is NOT part of the medical record and is protected information as part of [named Hospital] Performance Improvement Program. The person completing the Referral does not have to include their name. Medication errors/near miss with potential harm to the patient are reported to the patient's physician and nurse immediately. The Director of Pharmacy is also notified...Medications Brought From Home By Patient (Own Supply) [named Hospital #1] discourages the use of the patients own supply of home medications because this practice bypasses many of [named Hospital #1] medication safety efforts; however, in certain controlled situation, patients may take their own supply of homw [home] medications if ordered by the attending physician and after appropriate identification by the pharmacy...In the event the pharmacy does not stock the a medicatio...and there is no suitable formulary alternative, it may be necessary to use the patients own medication. Pharmacy will contact the nurse to see if the medication is with the patient. Nurse will bring the home medication. Pharmacy will identify patient's own medication before patient use...If deemed acceptable for use, the pharmacist will enter the medication using the "home med" function in the computer system so that the medications will appear on the electronic medication record and generate a barcoded label. 'Patient's own supply' medication will be stored in its original labeled container in the ADM under "medications not loaded" in the patients designated medication bin. Nurse will dispense "patient's own supply" medication from ADM, scan the patient and medication upon administration, which is documented on the electronic medical record..."

Review of the Hospital #1 policy "Processing Physician Orders" last revised 6/29/2021, revealed, "This policy is a guideline for processing and/or transcribing physician orders...Clarification of Orders If a physician order needs clarification, the duly authorized personnel will contact the physician and document physician clarification. Whenever nursing staff is unfamiliar with or questions an order, the following steps should be taken: Consult pharmacist for medication orders, Contact MD [Medical Doctor] who entered the order, if after completing steps [referenced above] the nurse still has questions about the order, contact immediate supervisor for assistance. Medication Orders Licensed staff will review the medication in the electronic medical record and acknowledge the five rights: Right patient, Right drug, Right route, Right dose, Right time..."

Review of the Hospital #1 policy "Haloperidol Parenteral Therapy (Haldol)" revised 5/17/2019, revealed, "...the Food and Drug Administration (FDA) strengthened warnings regarding the use haloperidol due to numerous reports of QT prolongation [extended interval between the heart contracting and relaxing] and Torsades de Pointes [a life threatening heart rhythm disturbance] when administered via the intravenous route ...The use of intravenous haloperidol is limited [Named Hospital #1]...the intravenous route of administration may be used in certain clinical situations...Critical Care...Anesthesia...Emergency Department...torsade de pointes has been reported with single intravenous haloperidol dose...Monitoring of the patient will be consistent with critical care guidelines...continuous cardiac monitoring...Vital signs...hourly at minimum...Blood Pressure...within 15 minutes of administration of the haloperidol..."

2. Medical record review for Patient #1 revealed a 41-year-old male with the following diagnoses: Cerebral Palsy, Lennox- Gastaut (a syndrome (LGS) is a complex, rare, and severe childhood-onset epilepsy syndrome characterized by multiple and concurrent seizure types), recurrent aspiration pneumonia, intellectual disability, jejunum tube (a soft plastic tube that delivers food and medicine to the small intestine). Patient #1 had a history of multiple hospitalizations secondary to aspiration pneumonia. Patient #1 presented to Hospital #1's emergency department on 7/2/2023 via emergency medical services from Hospital #2.

Review of the Emergency Medical Services (EMS) trip report dated 7/2/2023 revealed, " ...[named EMS unit] responded to [named Hospital #2] ICU [intensive care unit] for an emergent transfer to [named Hospital #1]...the patient was admitted 2 months ago due to aspiration. The patient was brought back recently due to aspiration pneumonia as well. The patient was intubated last week, but 2 days ago they extubated him...She [nurse at Hospital #2] informs EMS that he [Patient #1] is going to [named Hospital #1] due to needing pulmonology. The patient's chest Xray shows that his Lt [left] lung is not inflating due to a mucus plug in the Lt main stem bronchus. The patient is in need of surgery..." Patient #1 was transported to Hospital #1 on 7/2/2023 at 4:10 PM.

Review of Patient #1's medical record from Hospital #1 revealed, "Hospital Course...The patient suffered from acute respiratory failure with hypoxia (deficiency in the amount of oxygen reaching the tissues) and hypercapnia (presence of higher-than-normal level of carbon dioxide in the blood)..." The record revealed Patient #1's respiratory status continued to worsen, and he was reintubated on 7/5/2023 and required a bronchoscopy (procedure to look directly at the airways in the lungs) and pulmonary secretion removal (removal of mucus and secretions). Patient #1 was extubated on 7/10/2023 and was transferred to the Floor 1 Cardiac/medical unit on 7/14/2023.

Review of Patient #1's "Orders" dated 7/14/2023 at 8:36 AM, revealed "template non-formulary...Xcopri [medication used to treat partial-onset seizures (also called focal seizures) in adults] 50 mg [milligrams] tablet...Order Details: 1 tab...Tube QHS [every night at bedtime]...Use Patient Supply..." and at 8:46 AM, revealed "template non-formulary...clobazam (Onfi) [controlled medication used to treat seizures] 10mg tablet...Order Details: 1.5 tab, Tube...BID [twice daily]...Use Patient Supply [Xcopri and clobazam are controlled medications which are to be counted each shift per hospital policy]..."

Review of the "Medication Administration Record" dated 7/17/2023 at 21:19 (9:19 PM), revealed "...clobazam (Onfi) 10 mg tablet...15 mg...Tube..." administered by Nurse #1.

Review of the "Provider Notification" dated 7/18/2023 at 22:48 (10:48 PM), revealed Nurse #1 documented "...med error...yesterday night, patient was given 15 tabs [tablets] instead of 1.5 tabs = [equals] 15 mg [1.5 tabs of 10 mg would equal 15 mg], I had just realized this tonight, charge nurse and pharmacy aware [according to the facility's investigation, Nurse #1 administered 22.5 tablets (225 mg) of clobazam which equaled 15 doses of 1.5 tablets (15 mg)]..."

On 7/19/2023 at 7:57 PM, Physician #2's progress note revealed, "...Was notified by nursing team overnight and this morning...pt had inadvertently received 15 tabs of Onfi [clobazam] rather than 1.5 mg of Onfi [according to the facility's investigation, Nurse #1 administered 22.5 tablets (225 mg) of clobazam (Onfi) which equaled 15 doses of 1.5 tablets]..."...poison control was called who said no further intervention is required...the mother does report that he did seem more out of it yesterday..."

On 7/20/2023 at 1:52 PM, Nurse #6 documented on the Provider Notification, "[Patient #1's] mom says that he has new twitching/shaking in his right hand and left leg that have started since the medication discrepancies. I just wanted to make you aware...No orders received..." Nurse #6 notified Physician #2 about the concerns.

Review of the pharmacy Omnicell (automated medication dispensing system] reports for Patient #1 revealed there were no controlled substance counts for Xcopri or clobazam on the following dates: 7/15/2023 AM shift, 7/16/2023 AM and PM shifts, 7/17/2023 AM shift, 7/18/2023 AM shift, 7/24/2023 AM and PM shifts.

In an interview on 2/6/2024 at 12:20 PM Pharmacy Technician #1 stated he had been employed at Hospital #1 as a Pharmacy Technician for 12 years. Pharmacy Technician #1 stated on the night of 7/17/2023 the pharmacy got a call from the unit where Patient #1 was admitted saying there was not enough of a home medication (Xcopri) in the Omnicell to administer the prescribed amount. Pharmacy Technician #1 stated he walked to the unit, went to the Omnicell opened it and determined there was plenty of medication in the blister packs (prepackaged punch out medication cards with each separate dose in a punch). Pharmacy Technician #1 stated he then went to find the nurse (Nurse #1). Pharmacy Technician #1 stated he demonstrated to Nurse #1 that there were plenty of the home medications. Pharmacy Technician #1 stated he then dispensed one tablet of the medication Xcopri and explained to Nurse #1 it was just one tablet because he knew Nurse #1 had tried to dispense more than the ordered dose of Xcorpi. Pharmacy Technician #1 stated it was a seizure medication (Xcopri) that was non-formulary, and the hospital pharmacy did not stock an alternative so the prepackaged home meds (medications) were approved by pharmacy for use. Pharmacy Technician #1 then stated the following night, 7/18/2023, a Charge Nurse (Nurse #8) called and asked him to come down to the medication room because during count, Nurse #8 identified medications missing from the prepackaged seizure medication blister pack clobazam for Patient #1. Pharmacy Technician #1 stated it was determined Nurse #1 had given too many of the Clobazam tablets on 7/17/2023. Pharmacy Technician #1 stated Nurse #1 did not report she had given more than 1 dose of the clobazam on 7/17/2023 when he went to the medication room to assist her with the Xcopri medication. Pharmacy Technician #1 stated Nurse #8 had stopped Nurse #1 before she gave too many clobazam tablets on 7/18/2023. Pharmacy Technician #1 stated when he arrived at the medication room on 7/18/2023, there was a medication cup with several of the clobazam tablets, and he then took the 2-home seizure medication blister packages (clobazam and Xcopri) back to the pharmacy to discuss with the Pharmacist and develop another packaging system for the home medications. When asked if Nurse #1 understood when he explained the dose was for one tablet of the Xcopri on 7/17/2023, Pharmacy Technician #1 stated, "Yes, it seemed like she [Nurse #1] understood when I explained ..."

In a telephone interview on 2/6/2024 at 11:50 AM and a subsequent telephone interview at 12:30 PM due to Nurse #5 loosing cellular reception, Nurse #5 verified she worked as a Charge Nurse and had supervised Nurse #1 at times. Nurse #5 stated "Professionally she [Nurse#1] did well with patients and families...some communication issues simply because of language..." Nurse #5 stated she had no direct knowledge of the medication errors by Nurse #1.

In an interview on 2/6/2024 at 2:00 PM, Nurse #6 verified she documented on 7/20/2023 Patient #1's mother reported the twitching and shaking of Patient #1 after the patient had received 22.5 tablets of clobazam instead of the ordered 1.5 tablets by Nurse #1 on 7/17/2023. Nurse #6 stated she notified the physician of Patient #1's mother concerns.

In a telephone interview on 2/6/2023 at 2:10 PM, Nurse #7 verified she was a Charge Nurse and had worked with Nurse #1. Nurse #7 stated, "She [Nurse #1] was a sweet person, she was smart...we were cautious of her..." Nurse #7 gave an example, "If a patient's blood pressure dropped, she would not notify us right away..." Nurse #7 stated she did a controlled medication count at the end of her shift on 7/18/2023 with the on-coming night nurse (Nurse #8). Nurse #7 stated the process was to count controlled medication with each nursing shift change and generally the 2 charge nurses would count the controlled medications. Nurse #7 stated on 7/18/2023, when they counted Patient #1's home medications of clobazam in the prepackaged blister packs, she found a medication error. Nurse #7 stated she went to retrieve Nurse #1, who was already in Patient #1's hospital room with medications, and asked Nurse #1 to bring everything she had pulled for Patient #1 and return to the medication room. Nurse #7 stated Nurse #8 called the pharmacy to make them aware. Nurse #7 stated they informed Pharmacy Technician #1 the count was off, and many pills were missing. Nurse #7 stated, on 7/17/2023, Nurse #1 had pulled 15 doses (22.5 tablets) of clobazam instead of the 1.5 tablets ordered twice daily. Nurse #7 verified pharmacy worked immediately to change the process and removed the home medications from the Omnicell. Nurse #7 verified it was determined Nurse#1 had administered 15 doses of clobazam equaling 22.5 tablets instead of the ordered 1.5 tablets. Nurse #7 stated a count should have been completed on the morning of 7/18/2023, following the night shift of 7/17/2023. She further stated, "I don't know who that was or what they found." Nurse #7 confirmed Nurse #1 reported she had given the 15 doses of clobazam the night before on 7/17/2023. Nurse #7 stated she had worked with Nurse #1 on day shift when Nurse #1 was initially employed. Nurse #7 stated, "I recommended her for nights because it's slower paced...sometimes easier for new grads [nursing graduates]." Nurse #7 stated to her knowledge Patient #1 did not have any adverse reactions to the overmedication, but she also acknowledged the error was discovered 24 hours after the medication error. Nurse #7 stated she called poison control on 7/19/2023 when she returned to work, but by the time she called, it had been 48 hours since the overmedication and poison controls only recommendation was to continue to observe the patient. When asked about the delay in calling poison control, Nurse #7 stated "I don't know if [named Nurse #8] called poison control or not." Nurse #7 stated Physician #1 talked with Patient #1's mother on 7/19/2023 and made her aware of the medication incident.

In an interview on 2/6/2024 at 2:50 PM, the Nurse Educator stated she had been a clinical educator for 8 years. The Nurse Educator stated she was notified by Nurse #2 that Nurse #1 required additional education after an event in which Patient #1 had been administered 22.5 tablets of clobazam instead of the 1.5 tablets of clobazam. The Nurse Educator stated she did the teaching/education for Nurse #1 on 8/2/2023, and Nurse #1 came in on her off day for education. The Nurse Educator stated on 8/4/2023, 2 days after the re-education of Nurse #1, she was again notified by Nurse #2 to meet with Nurse #1 regarding a teachable moment where Nurse #1 cancelled current physician orders when the physician told Nurse #1, "No new orders," after Nurse #1 notified they physician of a critical lab. The Nurse Educator stated she met with Nurse #1 again on 8/4/2023. The Nurse Educator stated she provided education on clear communication with the physicians and to use the read back method anytime you are receiving physician orders.

In a telephone interview on 2/6/2024 at 6:25 PM, Nurse #8 verified she was a Charge Nurse and had supervised Nurse #1. When asked if she had any concerns for Nurse #1, she stated, " ...did discuss with other Charge Nurses and Educator because she was a new grad [nursing graduate]...checked on her frequently...at times I questioned whether there was language barrier..." Nurse #8 verified she conducted the controlled medication count with Nurse #7 on the evening of 7/18/2023, when Nurse #7 was going off shift and she was coming on shift. Nurse #8 verified the policy was to count controlled medications two times every 24 hour period, generally at shift change. Nurse #8 stated Nurse #7 had counted the previous evening (7/17/2023), and Nurse #8 knew the controlled medication count for clobazam was off from the previous controlled medication count (evening shift on 7/17/2023). Nurse #8 stated she called the pharmacy once the discrepancy was identified.

In an interview on 2/7/2024 at 10:05 AM, Physician #2 verified he had been the attending physician for Patient #1. Physician #2 stated he did recall the medication error that Nurse #1 administered 22.5 tablets of clobazam instead of the 1.5 tablets of clobazam ordered by the physician. Physician #2 stated he was notified the morning after Nurse #1 administered 22.5 tablets of clobazam instead of the 1.5 tablets of clobazam ordered by the physician. Physician #2 stated "...the medication was Onfi [clobazam] a seizure medicine...benzodiazepine." When asked if Patient #1 had been affected by the overmedication, Physician #2 stated, "He [Patient #1] was a little bit more out of it...drowsy." Physician #2 further stated, "It [receiving 22.5 tablets of clobazam] may have delayed his [Patient #1] hospitalization...not sure..." Physician #2 stated Patient #1 had been stable from a respiratory standpoint after receiving the wrong dose of 22.5 tablets of clobazam. Physician #2 verified he did discuss the medication error with Patient #1's family. Physician #2 stated it was his understanding that the seizure medications were non-formulary at that time and both Xcopri and clobazam were provided by the home medications packaged by another pharmacy and reviewed/labeled by the hospital pharmacy. Physician #2 stated he did not feel the wrong dose of clobazam escalated Patient #1's care. Physician #2 further stated, "...with all the meds [medications] he [Patient #1] got, clearing secretions may have been affected..." Physician #2 was asked if the incorrect dose of clobazam making the patient increasingly drowsy was his primary concern, and Physician #2 responded, "Yes." Physician #2 stated, "It shouldn't have happened...I would have mistrust of the hospital system if I were his [Patient #1] family...but I don't think it [the incorrect dose of clobazam] would cause any long-term issues..."

In an interview on 2/7/2024 at 12:20 PM, Pharmacist #1 verified she was working on 7/18/2023 when the nurses from Patient #1's unit notified pharmacy the medication count was off for Patient #1's home medications [clobazam]. Pharmacist #1 stated Pharmacy Technician #1 went to the medication room/Omnicell on the unit, since she as the Pharmacist was unable to leave the pharmacy. Pharmacist #1 stated the nursing staff were calling for assistance to reload the 15 doses (22.5 tablets) Nurse #1 pulled in error of the clobazam medication. Pharmacist #1 stated it was her understanding that Nurse #1 had administered 15 doses (22.5 tablets) of the clobazam the shift prior to 7/18/2023, when the clobazam count was discovered to be wrong. Pharmacist #1 verified she entered an occurrence report into the internal system when she was notified of the clobazam dosage error. When asked how common was the practice of using patient home medications in the hospital, Pharmacist #1 stated the pharmacy tried not to use home medications, but because the seizure medications (clobazam and Xcopri) were non-formulary, the hospital did not have any in stock. When asked to explain formulary versus non- formulary, Pharmacist #1 stated they don't stock every drug available because it's not fiscally responsible. Pharmacist #1 stated the pharmacy kept alternatives for many drugs in stock but for the Xcopri and clobazam, there was not an alternative drug that would be as effective. Pharmacist #1 stated Patient #1 was on quite a few formulary seizure medications, and he also had an allergy to Keppra (medication used to treat seizures). Pharmacist #1 stated after the medication error was discovered in which clobazam 22.5 tablets were admibnistered instead of the 1.5 tablets, the pharmacy changed the process for Patient #1's home medications, retrieved the medications to the pharmacy, put them into pill bottles with labels and required nursing staff to come to the pharmacy to retrieve the medications. Pharmacist #1 stated she had been employed in Hospital #1's pharmacy for 5 years and she had never seen a home medication in the blister/bubble packs, they were very uncommon. Pharmacist #1 stated generally if home medications were used, they were in pill bottles.

In an interview with the Director of Quality and Risk Management, Interim Director of Pharmacy, Administrative Director of Emergency Services and Cardiovascular Services, and Nurse #2 (Unit Manager) on 2/12/2024 at 9:35 AM, the surveyors reviewed the controlled medication counts documented for Patient #1's home seizure medications Xcopri and clobazam when Patient #1was on the first floor medical unit. The controlled medication count log revealed on 7/13/2023 at 6:30 PM, a "template non- formulary medication" was given the Item Identifier "NHOMEMED" with a count of 44. Nurse #2 explained to the surveyors that she was unsure if the "NHOMEMED" was the Xcopri or the clobazam. Nurse # 2 stated she was unsure if the nurses were doing one count on both the home medications of Xcopri and clozabam in the bubble pack. The surveyor asked whether one count on 2 separate seizure medications, that were classified as controlled medications, was correct hospital procedure. The Administrative Nursing Director of Emergency Services and Cardiovascular Services verified that was not following hospital protocol. The Interim Director of Pharmacy stated, "We have 40 million dollars in technology we were trained by Omnicell and Cerner [cloud-based electronic health record]...our own technology is insufficient [to manage home medications in Omnicell]...we did everything they told us to do...shame on the technology in Omnicell for not telling us what drug it is." The Interim Director of Pharmacy stated at the time Patient #1 was admitted to the hospital with the non-formulary home medications (Xcorpi and clobazam), the pharmacy staff had to enter the medication into the Omnicell as Nonformulary home medications and the report generated for the surveyors did not identify the medication by name.

Continued interview revealed, the Interim Director of Pharmacy verified the following medication counts were not documented for the nonformulary seizure medications: 7/15/2023 day shift, 7/16/2023 day and night shift, 7/17/2023 day shift, 7/18/2023 day shift. When asked who was responsible for monitoring nursing staff to ensure narcotic counts were completed according to policy, one time per shift, Nurse #2 stated "I am." Nurse #2 stated she reviewed the reports weekly, but a few days could pass before she realized the controlled medication counts were not completed. When asked if there was an investigation or any documentation to address the gaps identified in the controlled medication counts for Patient #1, Nurse #2 stated, "I don't know that we document that anywhere...we tell them [charge nurses] you have got to get your counts done..." Nurse #2 stated she had identified no pattern with a particular staff member, and it was unusual that there were several consecutive days when the counts were not done. Nurse #2 again stated there was no counseling or corrective actions documented, but she "had a conversation with them [charge nurses who failed to follow policy]..." The Administrative Director of Emergency Services and Cardiovascular Services verified there was no Corrective Action Plan to address the failure to complete controlled medication counts related to Patient #1.

In an interview on 2/12/2024 at 10:30 AM, the Interim Director of Pharmacy stated the home nonformulary medications (Xcorpi and clobazam) were loaded into Cerner, and they were at the mercy of Omnicell. She further stated the drug name converted to "template non-formulary" in Omnicell. The Interim Director of Pharmacy stated after this incident (administration of 22.5 tablets of clobazam instead of 1.5 tablets as ordered by the physician) with Patient #1, they investigated and made sure they had a standard process for home medication controlled medications, which was to keep those medications in the pharmacy for dispensing.

In an interview on 2/12/2024 at 3:33 PM, Pharmacy Technician #2 verified she had loaded Patient #1's home medications (Xcorpi and clobazam) in the Omnicell in the Floor 1 Cardiac unit on 7/13/2023. Pharmacy Technician #2 stated she could not recall if the 44 tablets listed when she loaded the medications were one (Xcopri or Clobazam) or both Xcopri and clobazam. Pharmacy Technician #2 stated she had worked at the hospital pharmacy for about 3 weeks in July 2023, but she had experience as a Pharmacy Technician at another hospital and was not new to the professional role. Pharmacy Technician #2 verified this was the first home medication she had loaded into the Omnicell at Hospital #1.

In an interview on 2/13/2024 at 9:45 AM, the Interim Pharmacy Director stated that seizure medications are rarely changed in the hospital setting due to the fine-tuned regimen managed outpatient. The Interim Pharmacy Director stated Patient #1 was on multiple seizure medications and verified two of the medications were non-formulary (Xcorpi and clobazam) and required the use of his home medications. The Interim Pharmacy Director stated the medications clobazam and Xcopri were prepackaged by another pharmacy because Patient #1 resided in a care home. The Interim Pharmacy Director stated she had worked at Hospital #1 for 10 years, and she had never encountered a home medication in the pre-packaged blister packages to be administered at the hospital; she stated it was very uncommon. Interim Pharmacy Director stated the 2-home medications (Xcorpi and clobazam) should have been entered as two individual medications in the Omnicell and verified that when the medications were loaded on the Cardiac/Medical first floor Omnicell, it appeared only one home medication was entered. The Interim Pharmacy Director stated her staff followed the instructions of Omnicell and labeled the medication as home medication non-formulary in the system, and verified there was no way to enter the name of the medication. The Interim Pharmacy Director stated, Cerner [EMR system] and Omnicell did talk to each other when a medication was entered into Cerner system, however the home medication caused a problem because Omnicell only recognizes it as a Non-formulary Home medication. The Interim Pharmacy Director stated the normal process for one- and one-half tablet prescription would be to pull two tablets from the Omnicell, cut one tablet in half and waste the other half of the tablet. The Interim Pharmacy Director stated because they were using Patient #1's home medications, Patient #1 had paid for, they were trying not to waste his medications. The Interim Pharmacy Director again verified the medication clobazam was packaged in blister packs with one- and one-half tablets per blister pack. The Interim Pharmacy Director stated after this incident the entire process and policy was changed for home medications; and all home medications in blister packages were now kept in the pharmacy and nurses were required to retrieve each dose from pharmacy.

In a telephone interview on 2/13/2024 at 11:07 AM, Nurse #9 (who was identified by Nurse #2 as failing to complete the counts for Patient #1's Xcopri and clobazam on 7/16/2023 AM shift, 7/17/2023 AM shift and 7/24/2023 AM shift, verified she was a charge nurse on the Floor one unit. Nurse #9 verified Nurse #2 was her unit manager. Nurse #9 stated she did not recall Patient #1 or his medications. Nurse #9 stated the Charge Nurses generally complete their controlled substance/narcotic counts at the end of their shift. When asked if there were times that she left her shift without counting the medications, Nurse #9 stated, "There are times when we miss them...sometimes we get caught in other things...we do try to pass on to the next shift that it [narcotic counts] has been missed." When asked what the purpose of completing the counts at the end of each shift, Nurse #9 stated, "I guess to make sure all controlled substances are accounted for and no discrepancies."

In an interview on 2/13/2024 at 11:21 AM, Nurse #2 stated it was not acceptable to miss the controlled medication counts. Nurse #2 stated, "I'm not sure what happened here [with Patient #1's home seizure medication counts for Xcopri and clobazam]..." Nurse #2 stated, "Our practice is to do the narcotic counts."

In a telephone interview on 2/13/2024 at 12:00 PM, Nurse #5 verified the Charge Nurses complete the narcotic/controlled substance counts once per shift. Nurse #5 stated she did recall counting some of Patient #1's home medications (Xcorpi and clobazam) that were in blister/bubble packages. When asked about the 7/15/2023 AM shift and 7/18/2023 AM shift missed controlled medication count for both Patient #1's home seizure medications Xcopri and clobazam, Nurse #5 stated, "I don't recall those mornings or why it would have been missed..."

In a telephone interview on 2/13/2024 at 12:10 PM, Nurse #1 verified she had been employed at Hospital #1 from 4/4/2022 through 8/15/2023. Nurse # 1 stated while she was employed at Hospital #1, she obtained her Bachelor of Science in Nursing and received that degree in May 2023. Nurse #1 verified the first-floor cardiac unit was her primary assignment and Nurse #2 was her unit manager. Nurse #1 stated she completed the Nurse Residency program at Hospital #1 for new graduates which included weekly classes. Nurse #1 stated she originally worked day shift when she was approached by Nurse #2 to work