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Based on interview and policy and procedure review, it was determined the facility failed to consider and report late doses of medication as medication errors. Failure to consider and report medications administered late did not allow the facility to track, trend and analyze medication errors related to the timing of medication administration. The above failure also did not allow the medical staff to be aware of the reasons for late medication administration and revise, if necessary, policies and procedures. The failed practice affected all patients admitted to the facility. Findings follow:

A. Review of the policy and procedure titled "MEDICATION ERRORS," received from the Chief Executive Officer on 01/07/14 revealed, under Policy, "#4 the following: By definition, the Medical Staff does not consider a "Late Dose" administered to the patient as the result of an extended medication pass as a medication error. No further documentation of the late dose or communication to the physician is necessary as longs as there was not harm to the patient, no intervention was required and the 6 RIGHTS of medication administration were followed."
B. During an interview with the Chief Nursing Officer and the Infection Control Nurse at 0845 on 01/08/14, both stated medications administered late are not considered medication errors and not reported to the medical staff as medication errors.

Based on observation and interview, the facility failed to ensure intravenous solutions located in one of one clean supply room on the Long Hall were secure. The potential existed for unauthorized individuals to access the intravenous solutions. Findings follow:

A. On 01/07/14 at 1400 and on 01/08/14 at 0900, the door to the Long Hall Clean Supply Room was open. The intravenous solutions in the room were not secure and were accessible to unauthorized persons. Intravenous solutions observed located in the room included Lactated Ringers Solution, Dextrose 5% Solution, Lactated Ringers with 5% Dextrose Solution, Dextrose 5% with .45% Sodium Chloride Solution and Sodium Chloride .45% Solution.
B. The Director of Pharmacy was interviewed on 01/07/14 at 1445. It was verified through interview that the intravenous solutions were placed in the room by the Central Supply Department, and the solutions were not secure.