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Based on observation, interview, and record review, the hospital failed to ensure the nursing staff implemented their P&Ps for the medication administration via injection for one of three sampled patients (Patient 1) as evidenced by:

1. The nursing staff did not change Patient 1's IV bag after 24 hours as per the hospital's P&P.

2. The nursing staff did not label Patient 1's IV tubing as per the hospital's P&P.

These failures had the potential to increase the risk of substandard healthcare outcomes and safety to the patient.

Findings:

1. Review of the hospital's P&P titled CORE: Administration of Medications via Injection, release date June 2022 showed under procedure, the 7 "R's" of administering medications will be followed with each medication administration: "Right" patient, "Right" medication, "Right" dose, "Right" time, "Right" route, "Right" reason, and "Right" documentation.

On 6/10/25 at 0839 hours, a medication pass observation was conducted for Patient 1, with RN 3. During the observation, a 250 ml bag of NS (normal saline, a mixture of water and salt with a salt concentration of 0.9%) was observed infusing at a TKO rate for Patient 1. The label on the IV bag showed "EXPIRES 24 HRS AFTER HANG TIME". The same label also showed that the bag was hung on 6/8/2025 at 2331 hours (approximately 33 hours from the initial hang time).

On 6/10/25 at 0900 hours, an interview was conducted with RN 3. RN 3 acknowledged the bag of NS for Patient 1 should have been changed 24 hours after the initial hung.

2. Review of Lippincott Manual of Nursing Practice revised August 19, 2024, provided by the hospital, showed to change a primary intermittent administration set every 24 hours. The same document also showed to label the administration set at the proximal and distal end to prevent dangerous misconnections.

On 6/10/25 at 0839 hours, during the same medication pass observation was conducted with RN 3. During the medication pass an observation was made, the IV tubing connected to the bag of NS running at a TKO rate was unlabeled.

On 6/10/25 at 0900 hours, an interview was conducted with RN 3. RN 3 acknowledged there was no way to identify when the IV tubing for Patient 1's was initiated and confirmed it should have been labeled.

On 6/10/25 the Director of Quality Management was notified and acknowledged the above findings.