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Based on interviews and document review, the facility failed to ensure medication orders were reviewed for appropriateness by a pharmacist or provider before the first dose of medications were administered. This failure was identified in two of three inpatient medical records reviewed. (Patient #2 and #3)

Findings include:

Reference:

According to the Colorado Department of Regulatory Agencies (DORA) Division of Professions and Occupations, Colorado Nursing Laws, Scope of Practice Algorithm, retrieved from: https://drive.google.com/file/d/0B-K5Dhx
XxJZbcm9vcEY2MmhTaTg/view?resourcekey=0-bXsLKpwyAIaWr0TZjBfsEQ, if the skill/task is not taught in the nurse's basic nursing program, if the nurse has not completed a comprehensive training program, including clinical experience related to the task, if the task is not routine in nursing literature and nursing practice, if the task does not pass the reasonable and prudent standard for nursing, then the task is not in the nurse's scope of nursing practice.

1. The facility failed to ensure medication orders were reviewed for appropriateness by a pharmacist or provider before the first dose of medications were administered.

A. Document Review

i. A review of Patient #2's medical record revealed Patient #2 presented to the facility on 8/12/25 at 11:22 a.m. for a right knee replacement surgery. Following the surgery, Patient #2 was admitted to the inpatient unit on 8/12/25 at 5:33 p.m. The medication administration record (MAR) revealed nursing staff administered cefazolin (an antibiotic) 1 g per (/) 50 mL on 8/13/25 at 8:11 a.m., aspirin (a medication used to reduce pain and prevent heart attacks and strokes) 81 mg and gabapentin (a medication used to treat nerve pain) 800 mg on 8/13/25 at 9:04 a.m., and clopidogrel (a medication used to prevent blood clots) 75 mg on 8/14/25 at 9:30 a.m., prior to a pharmacist or provider reviewing the medication orders for appropriateness.

The medication orders revealed a pharmacist verified the cefazolin 1 g/50 mL order on 8/13/25 at 3:38 p.m., approximately seven hours after the medication was administered. The aspirin 81 mg and gabapentin 800 mg orders were verified on 8/13/25 at 3:38 p.m., approximately 6 hours after the medications were administered. Finally, the clopidogrel 75 mg order was verified on 8/14/25 at 7:19 p.m., approximately 10 hours after the medication was administered.

ii. A review of Patient #3's medical record revealed Patient #3 presented to the facility on 10/9/25 at 12:34 p.m. for an endoscopic ethmoidectomy (a procedure to remove tissue and bone in the ethmoid sinuses that blocks natural drainage). Following the surgery, Patient #3 was admitted to the inpatient unit on 10/9/25 at 3:37 p.m. The MAR revealed nursing staff administered diltiazem (a medication used to lower blood pressure and treat irregular heart rhythms) 120 mg on 10/9/25 at 7:23 p.m., and tamsulosin (a medication used to relax the muscles in the prostate and bladder) 0.4 mg on 10/9/25 at 7:24 p.m., prior to a pharmacist or provider reviewing the medication orders for appropriateness.

The medication orders revealed a pharmacist verified the diltiazem 120 mg and the tamsulosin 0.4 mg on 10/9/25 at 9:18 p.m., approximately two hours after the medications were administered.

iii. Review of the Medication Management policy revealed nursing staff were expected to routinely review medication orders for the appropriateness of the drug, dose, frequency, and route of administration; therapeutic duplication; real or potential allergies or sensitivities; real or potential interactions with other medications, food, or laboratory values; contraindications for use; and other relevant medication-related issues or concerns. Medications were permitted to be administered prior to order verification by a pharmacist or provider.

This was in contrast with the to the DORA Scope of Practice Algorithm which read, if the skill/task was not taught in the nurse's basic nursing program, if the nurse had not completed a comprehensive training program, including clinical experience related to the task, if the task was not routine in nursing literature and nursing practice, if the task did not pass the reasonable and prudent standard for nursing, then the task was not in the nurse's scope of nursing practice.

Upon request, the facility was unable to provide nationally recognized guidelines to support medication orders being reviewed by nursing staff for appropriateness.

B. Interviews

i. An interview was conducted on 11/25/25 at 9:11 a.m. with registered nurse (RN) #1. RN #1 stated as a nurse, they reviewed medication "rights" such as right patient, right dose, right time, and right route before administering the medication to a patient. RN #1 explained they verified the right order and dose by scanning the medication and comparing it with the medication order. RN #1 stated if they thought a medication order was abnormal, they would reach out to a provider for clarification. RN #1 stated they knew if a medication order was abnormal from their experience administering medications. RN #1 stated if a medication was ordered by a provider, and had not been verified by a pharmacist, they would not have been comfortable administering the medication without calling a doctor or physician assistant.

ii. An interview was conducted on 11/24/25 at 3:37 p.m. with provider (Provider) #2. Provider #2 stated they ordered medications for patients in the inpatient unit. Provider #2 stated they were not sure if a pharmacist verified medication orders before nursing staff administered the medications. Provider #2 stated it was the role of a pharmacist to determine if there were any safety concerns with medication orders, including dosing concerns. Provider #2 stated it was in a nurse's scope of practice to view a medication order and contact a provider with any concerns. Provider #2 stated it was not within a nurse's scope of practice to review a medication order and make a determination if the medication order was appropriate or if the dose was safe for a patient. Provider #2 stated, similarly, it was not in a nurse's scope of practice to review medication orders and make determinations regarding interactions with other medications or lab values. Provider #2 stated it was important to have a physician or pharmacist review medications orders to ensure patient safety.