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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.618 Condition of Participation: Emergency Services, was out of compliance.

C-0886 Drugs and biologicals commonly used in life-saving procedures, including analgesics, local anesthetics, antibiotics, anticonvulsants, antidotes and emetics, serums and toxoids, antiarrythmics, cardiac glycosides, antihypertensives, diuretics, and electrolytes and replacement solutions. Based on observation and interviews, the facility failed to stock commonly used drugs used in life-saving procedures. Specifically, the facility stocked succinylcholine but failed to stock dantrolene, the reversal agent for malignant hyperthermia, in one of one observations of the emergency room (ER).

Based on observation and interviews, the facility failed to stock commonly used drugs used in life-saving procedures. Specifically, the facility stocked succinylcholine (a medication used during surgical procedures that paralyzes muscles) but failed to stock dantrolene, the reversal agent for malignant hyperthermia (a potentially fatal condition characterized by generalized muscle spasms, fever, fast heart rate, fast breathing, and increased demand for oxygen), in one of one observations of the emergency room (ER).

Findings include:

References:

According to the succinylcholine chloride package insert, succinylcholine is an ultra short-acting depolarizing skeletal muscle relaxant. Malignant hyperthermia (MH): Succinylcholine administration has been associated with acute onset of malignant hyperthermia, a potentially fatal hypermetabolic state of skeletal muscle. MH frequently presents as intractable spasm of the jaw muscles (masseter spasm) which may progress to generalized rigidity (stiffness), increased oxygen demand, tachycardia (rapid heart rate), tachypnea (rapid respiratory rate) and profound hyperpyrexia (increase in body temperature). Successful outcome depends on recognition of early signs, such as jaw muscle spasm, acidosis, or generalized rigidity to initial administration of succinylcholine for tracheal intubation, or failure of tachycardia to respond to deepening anesthesia. Intravenous dantrolene sodium is recommended as an adjunct to supportive measures in the management of this problem.

According to the Malignant Hyperthermia Association of the United States (MHAUS) guideline How Much Dantrolene Should be Available in Facilities Where Volatile Agents are Available or Administered, and Succinylcholine is Only Stocked on Site for Emergency Purposes read, in a small percentage of cases malignant hyperthermia appears to be triggered by succinylcholine alone in the absence of a volatile agent. Dantrolene must be available for all anesthetizing locations where MH trigger agents are used. MHAUS recommends that centers stock a minimum of 36 20-mg vials of Dantrium or Revonto (total dose 720 mg), or three 250 mg vials of Ryanodex (total dose 750 mg). These amounts of dantrolene were originally determined by the analysis of MH event data showing that some cases of acute MH required up to or more than 10 mg/kg body weight, and therefore these total dose amounts would suffice for the majority of average sized patients that develop MH.

The consensus of our experts was that the incidence of MH induced by succinylcholine alone is not rare enough to justify the absence of dantrolene wherever succinylcholine may potentially be administered. Facilities that stock and have the potential to administer any triggering agent, including succinylcholine without volatile agents, should have dantrolene immediately available in the event that a patient in that facility develops MH.

1. The facility failed to stock dantrolene, a medication used to mitigate the effects of malignant hyperthermia (MH), a possible side effect from the administration of succinylcholine.

a. Observations

i. On 5/9/23 at 9:25 a.m., observations were conducted in the facility's ER. The observations revealed a package for succinylcholine in the facility's rapid sequence intubation kit (a collection of medications and supplies used to emergently place a breathing tube). Observations did not reveal any dantrolene (a medication used to reverse the effects of MH) stocked in the ER.

According to the package insert for succinylcholine, succinylcholine administration had been associated with acute onset of MH. Successful treatment outcome depended on recognition of early signs of MH. Intravenous dantrolene sodium was recommended as an adjunct to supportive measures in the management of this problem.

The Malignant Hyperthermia Association of the United States (MHAUS) guideline How Much Dantrolene Should be Available in Facilities Where Volatile Agents are Available or Administered, and Succinylcholine is Only Stocked on Site for Emergency Purpose read, in a small percentage of cases malignant hyperthermia appeared to have been triggered by succinylcholine alone in the absence of a volatile agent. Dantrolene must have been available for all anesthetizing locations where MH trigger agents are used. The consensus of MHAUS's experts was that the incidence of MH induced by succinylcholine alone was not rare enough to justify the absence of dantrolene wherever succinylcholine may potentially have been administered. Facilities that stocked and had the potential to administer any triggering agent, including succinylcholine without volatile agents, should have had dantrolene immediately available in the event that a patient in that facility developed MH.

b. Interviews

i. On 05/09/2023 at 12:28 p.m., an interview was conducted with pharmacy tech (Tech) #1. Tech #1 stated succinylcholine was a drug that required close attention to the package insert as it could have caused patient death. She said the facility did not stock dantrolene. Tech #1 explained stocking reversal agents was important to keep patients from dying and to reverse negative medication effects.

ii. On 5/09/23 at 9:25 a.m., an interview was conducted with registered nurse (RN) #2. RN #2 said the facility stocked succinylcholine in the ER for muscle paralysis for rapid intubation. RN #2 was not familiar with dantrolene, and said the facility did not stock it.

iii. On 05/09/2023 at 12:57 p.m., an interview was conducted with Pharmacist #3. Pharmacist #3 stated the facility stocked succinylcholine for use during intubation. She explained succinylcholine paralyzed the skeletal muscles. Pharmacist #3 said dantrolene reversed the effects of MH. She further said untreated MH could have led to rhabdomyolysis (muscle breakdown) which then damaged the kidneys. Pharmacist #3 stated not having dantrolene readily available could have led to worsening MH, up to and including patient death.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.635 Condition of Participation: Provision of Services, was out of compliance.

C-1016 Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. Based on observations and interviews, the facility failed to ensure expired drugs were not available for patient use in one of one observations in the emergency department.

C-1024 General (i) The CAH provides those diagnostic and therapeutic services and supplies that are commonly furnished in a physician's office or at another entry point into the health care delivery system, such as a low intensity hospital outpatient department or emergency department. These CAH services include medical history, physical examination, specimen collection, assessment of health status, and treatment for a variety of medical conditions. Based on observation, document review, and interviews, the facility failed to provide diagnostic services that were commonly furnished in another entry point into the health care delivery system, such as an emergency department. Specifically, the facility failed to screen for suicidal intentions using a questionnaire specifically designed to screen for this condition and in accordance with facility policy in three of three medical records reviewed for suicide screening.

C-1046 Nursing services must meet the needs of patients. (1) A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient's needs and the specialized qualifications and competence of the staff available. Based on document review and interviews, the facility failed to ensure facility policies and national standards and guidelines were followed to ensure orientation was completed and documented in two of two registered nurses' personnel files reviewed. Specifically, these nurses were allowed to perform registered nurse duties independently prior to completing orientation and having the orientation documented.

C-1049 All drugs, biologicals, and intravenous medications must be administered by or under the supervision of a registered nurse, a doctor of medicine or osteopathy, or, where permitted by State law, a physician assistant, in accordance with written and signed orders, accepted standards of practice, and Federal and State laws. Based on observations and interviews, the facility failed to ensure facility policy was followed to verify patients' identities while administering medications in two out of two medication administrations observed.

Based on observations and interviews, the facility failed to ensure expired drugs were not available for patient use in one of one observations in the emergency department.

Findings include:

Facility policy:

According to the policy Pharmacy Outdates, medications are checked monthly for any outdates. The outdates are entered in the inventory program and apha expire worksheet. The dates are also physically checked on each drug for outdate. The pharmacy medication room and the emergency department outdates are checked by pharmacy staff.

1. The facility failed to ensure outdated medications were not available for patient use. Specifically, expired fluids were stocked in the emergency room (ER).

a. Observations

i. On 5/9/23 at 9:25 a.m., observations were conducted in the facility's ER. The observations revealed a bin with approximately 20 bags of 500 milliliter (mL) bags of intravenous (IV) 5% dextrose with an expiration date of April 2023. Additionally, observations revealed a bin with approximately 20 bags of 1000 mL bags of IV 10% dextrose with an expiration date of April 2023.

These observations were in contrast to the facility policy Pharmacy Outdates which read, medications were checked monthly for any outdates. The dates should have been physically checked on each drug for outdate. The pharmacy medication room and the emergency department outdates were checked by pharmacy staff.

b. Interviews

i. On 5/09/23 at 9:25 a.m., an interview was conducted with registered nurse (RN) #2. RN #2 said it was not appropriate to use expired medications during patient care. She further said a medication past its expiration date may not work as effectively.

ii. On 05/09/2023 at 12:28 p.m., an interview was conducted with pharmacy tech (Tech) #1. Tech #1 stated she checked the ER monthly to remove expired medications. She said every medication had an expiration date, and she placed a sticker with a large expiration date on bags of fluid. Tech #1 explained medications past the expiration date could break down over time.

iii. On 05/11/2023 at 11:26 a.m., an interview was conducted with medical doctor (MD) #4. MD #4 said physicians ordered 5% and 10% dextrose IV bags for babies who experienced low blood sugars. He also said physicians would order those fluid types for adults who were unable to take nutrition by mouth and needed intravenous fluid to maintain hydration and blood sugar levels.

iv. On 05/09/2023 at 12:57 p.m., an interview was conducted with Pharmacist #3. Pharmacist #3 stated the expiration date on medications should have been followed because past that date the manufacturer did not guarantee dosage or efficacy. She further stated a patient receiving an expired medication may not get the full intended dose.

Based on observation, document review, and interviews, the facility failed to provide diagnostic services that were commonly furnished in another entry point into the health care delivery system, such as an emergency department. Specifically, the facility failed to screen for suicidal intentions using a questionnaire specifically designed to screen for this condition and in accordance with facility policy in three of three medical records reviewed for suicide screening. (Patients #4, #6, and #29)

Findings include:

Facility policy:

According to the policy Assessment for Self-harm/Suicide Risk, the purpose of the policy was to prevent self-injury and ensure patient safety. All patients admitted to the emergency department or the hospital will be assessed for risk of self-harm.

Upon admission to the emergency department or hospital, the registered nurse or licensed practical nurse will complete the Columbia-Suicide Severity Rating Scale Screen. If the patient answers no to questions 1 and 2, no further action is required. The negative screen will be documented in the patient's chart. If the patient answers yes to questions 1 and/or 2, the full screening is completed.

Nurses will be educated upon hire & annually regarding the Columbia-Suicide Severity Rating Scale, this policy, and suicide risk precautions.

References:

According to UpToDate Suicidal Ideation and Behavior in Adults reviewed April 2023 and provided by the facility, a number of standardized scales have been proposed to evaluate suicide risk, but none is associated with a high predictive value. Depression rating scales are commonly used, but these are better measures of depression severity than suicide risk. As an example, a study evaluated responses to item number nine from the Patient Health Questionnaire - Nine Item (PHQ-9)("Over the last two weeks, how often have you been bothered by thoughts you would be better off dead or of hurting yourself in some way?") and found that the cumulative risk of suicide over one year among outpatients who answered "nearly every day" was 4 percent. In cardiac inpatients with current emotional distress (n=366), a positive response to item nine was endorsed by 21 percent, but a detailed suicide evaluation found that suicidal plans or intent were present in only 3 percent. Other studies also suggest that item nine is an insufficient assessment tool.

According to UpToDate Suicidal Ideation and Behavior in Children and Adolescents: Evaluation and Management reviewed April 2023 and provided by the facility, for youth evaluated in the emergency department by non-mental health clinicians, a brief screening tool may have some value in identifying risk for suicidal behavior.

Risk assessment of suicidal ideation - once a child or adolescent has disclosed suicidal ideation, prompt assessment of suicidal risk is in order. Assessing the risk for suicide in youth with suicidal ideation includes evaluation of multiple elements. Content and chronicity of the suicidal thoughts, existence and details of a suicidal plan, access to the means described in the plan, the level of intent (e.g. "I'm really gonna do it," stressors, emotional pain, behavioral regulation, and suicidal support.

Risk assessment information should be obtained from the parents or guardians, as well as the child or adolescent. Collateral information is necessary because the patient may have reason to provide inaccurate information (e.g. to avoid hospitalization).

The psychiatric evaluation is conducted after the patient is medically stable. The goals of the psychiatric evaluation include: Determining the risk of subsequent suicide attempt or suicide completion, identifying any predisposing and precipitating factors that can be treated or modified, recommending the level of care (i.e. inpatient, partial hospital, or outpatient care).

1. The facility failed to screen for suicidal intentions using a screening tool designed for this purpose and required per facility policy.

a. Observations

i. On 5/9/23 at 9:25 a.m., observations were conducted in the facility's emergency room (ER). The observations revealed staff using a Patient Health Questionnaire-9 (PHQ-9) to screen patients for suicidal intentions.

This observation was in contrast to the policy Assessment for Self-harm/Suicide Risk which read, upon admission to the emergency department or hospital the registered nurse (RN) or licensed practical nurse should have completed the Columbia-Suicide Severity Rating Scale Screen (CSSRS). If the patient answered no to questions 1 and 2, no further action was required. The negative screen should have been documented in the patient's chart. If the patient answers yes to questions 1 and/or 2, the full screening should have been completed.

b. Document review

i. Review of Patient #4's medical record revealed she was a 15-year-old girl who came to the ER on 3/14/23 after intentionally overdosing on psychiatric medications. The medical record included a copy of her suicide note. However, the facility was unable to provide evidence staff completed a suicide screen on Patient #4.

This medical record review was in contrast to the policy Assessment for Self-harm/Suicide Risk which read, the purpose of the policy was to prevent self-injury and ensure patient safety. All patients admitted to the emergency department or the hospital should have been assessed for risk of self-harm. Upon admission to the emergency department or hospital, the registered nurse or licensed practical nurse should have completed the Columbia-Suicide Severity Rating Scale Screen.

The medical record review was also in contrast to the UpToDate reference Suicidal Ideation and Behavior in Children and Adolescents: Evaluation and Management which read, once a child or adolescent has disclosed suicidal ideation, prompt assessment of suicidal risk was in order. Assessing the risk for suicide in youth with suicidal ideation included evaluation of multiple elements: Content and chronicity of the suicidal thoughts, existence and details of a suicidal plan, access to the means described in the plan, the level of intent (e.g. "I'm really gonna do it," stressors, emotional pain, behavioral regulation, and suicidal support).

The reference further read, risk assessment information should have been obtained from the parents or guardians, as well as the child or adolescent. Collateral information was necessary because the patient may have reason to provide inaccurate information (e.g. to avoid hospitalization). The psychiatric evaluation was conducted after the patient was medically stable. The goals of the psychiatric evaluation included: Determining the risk of subsequent suicide attempt or suicide completion, identifying any predisposing and precipitating factors that can be treated or modified, and recommending the level of care (i.e. inpatient, partial hospital, or outpatient care).

ii. Review of Patient #6's medical record revealed he came to the ER on 9/14/22 for suicidal ideation (suicidal thoughts or ideas). ER staff completed a PHQ-9 for Patient #4.

This medical record review was in contrast to the policy Assessment for Self-harm/Suicide Risk which read, upon admission to the emergency department or hospital, the registered nurse or licensed practical nurse should have completed the Columbia-Suicide Severity Rating Scale Screen.

This medical record review was also in contrast to the UpToDate reference Suicidal Ideation and Behavior in Adults which read, depression rating scales were commonly used to evaluate risk for suicide, but these were better measures of depression severity than suicide risk. As an example, a study evaluated responses to item number nine from the PHQ-9 ("Over the last two weeks, how often have you been bothered by thoughts you would be better off dead or of hurting yourself in some way?") and found that the cumulative risk of suicide over one year among outpatients who answered "nearly every day" was 4 percent. In cardiac inpatients with current emotional distress (n=366), a positive response to item nine was endorsed by 21 percent, but a detailed suicide evaluation found that suicidal plans or intent were present in only 3 percent. Other studies also suggested item nine was an insufficient assessment tool.

iii. Review of Patient # 29's medical record revealed he was admitted to the facility for sepsis (an infection in the blood stream). Hospital staff completed a Patient Health Questionnaire-2 (PHQ-2) for Patient #29. Staff did not complete a PHQ-9, because Patient #29 answered no to both screening questions on the PHQ-2 and therefore the PHQ-9 was not indicated.

The medical record reviews was in contrast to the policy Assessment for Self-harm/Suicide Risk which read, the purpose of the policy was to prevent self-injury and ensure patient safety. Upon admission to the emergency department or hospital, the registered nurse or licensed practical nurse should have completed the Columbia-Suicide Severity Rating Scale Screen.

iv. Training file reviews were completed for RN #2, RN #5, and RN #6. The files did not contain evidence of initial and annual training on the CSSRS.

These reviews were in contrast to the facility policy Assessment for Self-harm/Suicide Risk which read, nurses should have been educated upon hire and annually regarding the Columbia-Suicide Severity Rating Scale, this policy, and suicide risk precautions.

c. Interviews

i. On 5/10/23 at 9:19 a.m., an interview was conducted with RN #5. RN #5 said the facility expected nursing staff to perform a PHQ-2 for all patients older than 12. She explained if a patient answered yes to either or both questions on the PHQ-2 staff would then complete a PHQ-9. She explained the PHQ questionnaires screened for depression. RN #5 also said if staff used the wrong tool to screen for suicide there was a risk of patients leaving the facility and either harming or killing themselves.

This interview was in contrast to the facility policy Assessment for Self-harm/Suicide Risk which read, upon admission to the emergency department or hospital, the registered nurse or licensed practical nurse should have completed the Columbia-Suicide Severity Rating Scale Screen.

ii. On 05/11/2023 at 11:26 a.m., an interview was conducted with chief nursing officer (CNO) #8. CNO #8 said the facility used the PHQ screens instead of the CSSRS due to decisions made by a previous chief nursing officer. She stated if the wrong tool were used to screen for suicidal ideation, patients had a higher risk for suicide.

iii. On 05/11/2023 at 11:26 a.m., an interview was conducted with medical doctor (MD) #4. MD #4 was given a copy of the PHQ-9 and the CSSRS to review. He said the PHQ-9 was a depression questionnaire, and the CSSRS was more specific and detailed to screen for suicide risk. MD #4 said if staff used an screening tool not validated for suicide, they could miss suicidal intention and a patient could die.

Based on document review and interviews, the facility failed to ensure facility policies and national standards and guidelines were followed to ensure orientation was completed and documented in two of two registered nurses' personnel files reviewed. Specifically, these nurses were allowed to perform registered nurse duties independently prior to completing orientation and having the orientation documented.

Findings include:

Facility policies:

According to the Continuing Educational Requirements Nursing Policy, all nurses who care for patients in the emergency department and acute care will be certified in the following courses: Advanced Cardiopulmonary Life Support (ACLS), Pediatric Advanced Life Support (PALS), and Trauma Nurse Core Course (TNCC).

According to the Restraint Policy, training and competency is completed initially on orientation and annually.

According to the Safety Policy, employees responsible for handling infectious waste will be oriented upon employment and yearly thereafter on the risks and methods of handling these wastes.

References:

The New hire orientation day: Licensed Practical Nurse (LPN) - Competency Checklist lists the following competencies for LPNs: Swing bed protocols & Standing order sets, Lifts - Hoyer & EZ Lift, Suprapbic - care and change, Swing bed medication ordering process, Medication administration, Restraint use and documentation of restraints, Zoll Defibrillator and Crash Cart, Glucometer - blood glucose testing & control tests.

The New hire orientation day: Registered Nurse (RN) - Competency Checklist lists the following competencies for RNs: Swing bed protocols, Skin Tear protocol, Shelter in place - swing bed south, Lifts - Hoyer & EZ Lift, Surprpubic - care and change, Swing bed medication ordering process, IV's & IV pumps - including priming tubing and using smart pumps for IV drips, Medication administration and scanning, Restraint use and documentation of restraints, Zoll Defibrillator and Crash Cart, Preparing for and assisting with intubation, Glucometer - blood glucose testing & control tests, Bair Hugger, SCD's Bedside cardiac monitor, remote telemetry, portable monitors, Intraosseus insertion and maintenance, Chest tube insertion and care of the patient with a chest tube.

1. The facility failed to provide orientation and document the orientation in the employee file as assurance the registered nurses were competent to perform patient care in accordance with the scope of a registered nurse in an independent manner. Additionally, the facility failed to follow policy requirements of a nurse being certified in Pediatric Advanced Life Support (PALS) and Trauma Nursing Core Course (TNCC) before working in the emergency department (ED).

a. Document Review

i. An employee personnel file review for RN #5 revealed the RN was hired on 4/10/15. The review revealed there was no documentation of initial new employee orientation for RN #5. The RN competency checklist was in the file, however, it was blank.

ii. The employee record review for RN #6 revealed the RN was hired on 3/17/23. Further review revealed there was no competency checklist for new employee orientation.The record review also revealed RN #6 had no certification for PALS or TNCC. This was in contrast to the Continuing Educational Requirements Nursing Policy that read it was a requirement for RNs who worked in the ED to be certified in PALS and TNCC.

b. Interviews

i. On 5/10/23 at 7:55 a.m., an interview was conducted with RN #6. RN #6 stated she worked previously as an LPN until 3/17/23 when she received her license as a registered nurse. RN #6 stated she has been working as a new graduate nurse at the facility for approximately the last two months. RN #6 stated her responsibilities included being a resource who floated from unit to unit, conducting the role of charge nurse, and working in the ED. RN #6 stated she was unsure about her Advanced Cardiac Life Support Certification but had not obtained her PALS or TNCC certification yet. RN #6 also stated she had not started an orientation program yet after getting her RN license. RN #6 stated she did not need a structured orientation as an RN because she had experience in the facility as an LPN. She stated that when necessary, she utilized other nurses in the facility to answer questions about the patient care she was providing. RN #6 stated the difference between duties performed by an RN and an LPN were that RNs administered intravenous medications (IV's), conducted initial assessments, provided initial patient education, and provided assistance with lab draws. RN #6 stated she felt comfortable doing these RN responsibilities because she learned them in school. RN #6 stated she had future plans this fall to complete her formal orientation. RN #6 stated orientation was important so new staff would not learn in chaotic situations and had a second person who watched situations in the ED for patient safety.

This was in contrast to the facility policy Continuing Educational Requirements Nursing Policy which read, all nurses who cared for patients in the emergency department and acute care would be certified in the following courses: Advanced Cardiopulmonary Life Support (ACLS), Pediatric Advanced Life Support (PALS), and Trauma Nurse Core Course (TNCC).

ii. On 5/10/23 at 12:00 p.m., an interview was conducted with RN #5. RN #5 worked as an LPN until 2005 when she became an RN. She stated at that time, she received 30 days of orientation. She left the facility for approximately a year and then returned to work as an RN. She stated she received no additional orientation at that time. RN #5 stated orientation was important so the new employee could learn from someone with experience in order to know what to expect while performing the job.

iii. On 5/11/23 at 10:32 a.m., an interview was conducted with the chief nursing officer (CNO) #8. CNO #8 stated the facility used general checklists for staff orientation. The checklist was different for LPNs and RNs. She stated the practice was to give new hires four to six weeks of orientation. CNO #8 stated orientation for the charge nurse role was different from the orientation for the RN. CNO #8 stated she offered RN #6 orientation and RN #6 declined for a later date. CNO #8 stated it might not have been best practice, but it worked for them and she encouraged RN #6 to get help from other resources when necessary. CNO #8 stated orientation was important for patient safety, quality of patient care, and the quality of nurses learning process and performance. CNO #8 stated orientation was important so nurses learned how to provide safe care for patients and it was the RN's responsibility to keep patients safe. CNO #8 stated the risk of not having a nurse complete orientation was patient safety. She stated orientation provided the information RNs needed to perform their job and orientation kept them from making mistakes during patient care.

Based on observations and interviews, the facility failed to ensure facility policy was followed to verify patients' identities while administering medications in two out of two medication administrations observed.

Findings include:

Facility Policy:

According to the Medication Administration Protocol Policy, all medication administration must be done in accordance with State and Federal law, as well as within the Scope of Practice by the person administering the medications. Furthermore, the nurse on duty will verify the 5 rights before administering any medications. Right patient - by means of name and DOB and in accordance with the hospital's patient identification policy.

1. The facility failed to ensure a process was in place for staff to identify a patient when medications were administered to the patient.

a. On 5/9/23 at 11:50 a.m., an observation was conducted on the inpatient acute care unit to observe licensed practical nurse (LPN) #7 perform medication administration to the patients in the unit. The medications were listed on a card kept in a drawer that had the patient's name on the card. LPN #7 pulled the card from the drawer and matched the medication to the medication administration record (MAR) on the computer. LPN #7 then pushed the medication out of the pill pack and into an unlabeled medication cup. She then locked the medication cart and walked over to the patient to administer the medication. LPN #7 called the patient by first name, the patient responded by saying yes and LPN #7 gave the patient the medication. The patient did not have a name band on. LPN #7 repeated this process until all patients received their medication. None of the patients wore a name band or any type of identification. There were no identifiers used by LPN #7 while passing medications other than the patient's first name.

i. On 5/10/23 at 11:34 a.m., an observation was conducted on the inpatient acute care unit to observe LPN #7 perform medication administration to the patient in the unit. The observation revealed LPN #7 located the patient's MAR on the computer, matched the medication from the MAR with the medication card in the drawer, and pushed the medication from the pill pack to the unlabeled medication cup. LPN #7 then took the medication to the patient, called the patient by their first name, and gave the patient the medication to take. LPN #7 repeated this process until all patients received their medication. None of the patients wore a name band or any type of identification. There were no identifiers used by LPN #7 while passing medications other than the patient's first name.

Both observations were in contrast to the facility's Medication Administration Protocol Policy which read, all medication administration must be done in accordance with State and Federal law, as well as within the Scope of Practice by the person administering the medications. Furthermore, the nurse on duty would verify the five rights before administering any medications, including the patient's name and date of birth.

b. On 5/10/23 at 11:50 a.m., an interview was conducted with LPN #7. LPN #7 stated it was not the practice to use two patient identifiers while passing medications to the patients. LPN #7 stated she used the picture in the electronic medical record when she used the MAR to set up the patient medications. LPN #7 stated she did not believe she needed to use any other identifiers in medication administration because she was familiar with the patients. She stated staff updated the pictures when necessary in the medical record. LPN #7 stated the importance of using two patient identifiers while passing medication was to ensure the correct patients received the correct medications. She stated using two patient identifiers for medication administration was to ensure patient safety.

This was in contrast to the facility's Medication Administration Protocol Policy which read, all medication administration must be done in accordance with State and Federal law, as well as within the Scope of Practice by the person administering the medications. Furthermore, the nurse on duty would verify the five rights before administering any medications, including the patient's name and date of birth.