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Based on a staff interview, facility policy review, and review of the Advanced Cardiac Life Support (ACLS) guidelines, it was determined that the facility failed to administer emergency medications within the recommended time interval in accordance with facility policy as evidenced by documentation on the Cardiopulmonary (CPR) Record.

Findings include:

Facility policy titled, "Medication Administration - IV [intravenous] Push" (revised 08/24) stated, " ...III. Critical/Emergency IV Medications ... Registered Nurses ... may administer the following medications ... as per the ACLS protocol ... Epinephrine - 1.0 mg [milligram] as a rapid infusion and repeat at 3-5-minute intervals."

On 09/20/25 at 6:35 AM and at 6:37 AM, in the medication section of the CPR record, "epinephrine 1 mg IV" was documented as administered to Patient (P)1.

The facility failed to administer epinephrine within the recommended time interval in accordance with facility policy and ACLS guidelines. The second dose of epinephrine was given within two minutes of the first dose. The recommended time interval is three to five minutes between administrations.

The above finding was confirmed by Staff (S)1.

Based on a staff interview, review of facility policy, and review of facility documents, it was determined that the facility failed to ensure that: 1) all staff who administer emergency medications on the Cardiopulmonary (CPR) Record are documented; and 2) the full name and title of the staff member in the "Meds [medications] given by" column of the CPR record the dose and route of which a medication is administered is documented.

Findings include:

Facility policy titled, "Code Blue" (revised 08/24), stated, "... Procedure... 11. The role of the personnel in a Code Blue is follows: a. Registered Nurse... 4. Document on Cardiopulmonary Record..."
1. At the bottom of the CPR record for Patient (P)1, an area for a staff member's signature and printed name appears and requests the corresponding staff to fill in whomever fulfilled the roles of "RN [Registered Nurse] Transcriber, RT [Respiratory Therapist], MD [Doctor of Medicine], and Meds [medications] given by."

The CPR record failed to identify Staff (S)10 as a staff member who administered one milligram of epinephrine during the Code Blue.

On 10/01/25 at 10:50 AM, a telephone interview was conducted with S10 who stated, "based on the [defibrillator] rhythm strip, I gave one dose of Epi [epinephrine]."

The above findings were confirmed by S10.

2. On 09/20/25 at 6:45 AM, in the medication section of P1's CPR record, sodium bicarb [bicarbonate] (a medication used in medical emergencies during a cardiac arrest) was documented as administered.

The CPR record lacked evidence of the dose and route of which the medication was administered.

The CPR record failed to identify the staff member's full name and title who administered medication during the Code Blue. Only a first name was provided.

The above findings were confirmed by S1.