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Based on a review of facility documents and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure the protection and promotion of the rights of patients and failed to provide care in a safe setting (0144); the facility failed to ensure that a Registered Nurse administered an intramuscular medication (IM) the appropriate route. The medication was administered intravenous (IV).

This situation constitutes an Immediate Jeopardy situation.

Findings include:

1) Based on staff interview (EMP) and review of the medical record and facility documents, it was determined that the facility failed to ensure that a Registered Nurse administered an intramuscular medication (IM) the appropriate route. The medication was administered intravenous (IV). (144)

Cross reference with:
482.13 Patient Rights(c)(2) The patient has the right to receive care in a safe setting.

Based on a review of facility policy and medical records (MR) and staff interview (EMP), it was determined that facility failed to ensure that competent care was provided to a patient for one of one medical record reviewed (MR1).

Findings include:


A review of the facility policy "Electronic Medication Administration" dated April 2014, revealed, "The Registered Nurse, Licensed Practical Nurse, Graduate Nurse, and Respiratory Therapist will be responsible for recording medications administered to the patient via the Electronic Medication Administration Record using the Five Rights of Medication Administration in conjunction with the use of an approved Bar Code Scanning Device ...To provide measures of safety in the medication administration process by ensuring that the five rights of medication administration-right patient, right drug, right dose, right time, and right route are met with the system automated approach to perform a second validation of the five rights of medication administration ... ."


During an interview on April 13, 2017, at 2:00PM, EMP7 was asked about the administration of a medication IM (intramuscular) via IV (intravenous). EMP7 stated, "I just made a mistake. I did not read the instructions. I did not realize it until [MR1's] blood pressure dropped."

During a telephone interview on April 13, 2017, at approximately 2:00 PM, EMP8 stated, " I was not in the room when it happened. [MR1 ' s] condition was deteriorating, not responding. I asked the nurse what medication had been given. [EMP7] told me Geodon. I said they have been giving that IM. [EMP7] admitted to administrating the Geodon IV."

Based on review of facility documentation, medical record (MR), and staff interview (EMP), it was determined that the facility failed to provide nursing services consistent with professionally recognized standards of nursing practice (405); the facility failed to ensure that medications must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioner's responsible for the patient's care, for one of one medical record. (MR1)

This situation constitutes an Immediate Jeopardy situation.

Findings include:

1) Based on staff (EMP) interview and medical record review (MR) it was determined that the facility failed to ensure that medications must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioner's responsible for the patient's care, for one of one medical record. (MR1). (405)

Cross reference with:
482.23 Nursing Services (c) Preparation and Administration of Drugs.

Based on a review of facility policy and medical records (MR) and staff interview (EMP), it was determined that the facility failed to ensure that medications were prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioner's responsible for the patient's care for one of one medical record reviewed (MR1).

Findings include:

A review of the facility policy "Electronic Medication Administration" dated April 2014, revealed, "The Registered Nurse, Licensed Practical Nurse, Graduate Nurse, and Respiratory Therapist will be responsible for recording medications administered to the patient via the Electronic Medication Administration Record using the Five Rights of Medication Administration in conjunction with the use of an approved Bar Code Scanning Device ...To provide measures of safety in the medication administration process by ensuring that the five rights of medication administration-right patient, right drug, right dose, right time, and right route are met with the system automated approach to perform a second validation of the five rights of medication administration ... ."


During an interview on April 13, 2017, at 2:00PM, EMP7 was asked about the administration of a medication IM (intramuscular) via IV (intravenous). EMP7 stated, "I just made a mistake. I did not read the instructions. I did not realize it until [MR1's] blood pressure dropped."

During a telephone interview on April 13, 2017, at approximately 2:00 PM, EMP8 stated, " I was not in the room when it happened. [MR1 ' s] condition was deteriorating, not responding. I asked the nurse what medication had been given. [EMP7] told me Geodon. I said they have been giving that IM. [EMP7] admitted to administrating the Geodon IV."