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Based on record review and interview, the facility failed to ensure medications were transcribed to the Medication Administration Record (MAR) and administered as ordered by the physician for 1 of 3 patients (Patient # 3) reviewed.

The facility failed to ensure nursing staff noted, transcribed, and administered physicians' medication orders for patient #3.
This deficient practice had the likelihood to cause harm to all patients receiving treatment in the facility.

Findings include:
Record review of the Physician's Orders for patient #3, dated 06/19/20 to 07/02/20, revealed the following:

- 06/29/20 at 1050: Erythromycin ophthalmic eye ointment 0.5%, 5grams/gram to Left eye Four times daily (QID).
- 06/29/20 at 1340: Erythromycin ophthalmic eye ointment usp 0.5% to eyeball QID.
- 06/29/20 at 1340: Lacrilube to eye every four hours (Q4).
- 06/29/2 at 1340: remove eye patch.

Record review of the Medication Administration Record (MAR), dated 06/19/20 to 07/02/20, for patient #3 revealed that the physician's orders for the Erythromycin ophthalmic eye ointment, Lacrilube, and to remove the patient's eye patch had not been transcribe by the nursing staff onto the MAR. Further review revealed that the medications had not been given/ ordered from pharmacy by nursing staff.

Record review of the interdisciplinary notes revealed no evidence that nursing staff had acknowledged the physician's orders for the eye ointments and/or ordered the medications from the pharmacy or attempted to administer them to patient #3 as ordered.

Record review of the facility policy entitled: Medication Administration Record and Medication Administration; Policy number NSG 29; Review date April 2017; Revealed the following information:

MAR Procedure:
-General Instructions for Transcribing and Checking Orders:
-All active orders will be printed by pharmacy on the MAR. Any new orders after pharmacy prints MARS will be transcribed on the MAR by the Nursing staff.

-The Nurse will check all new orders entered by pharmacy and acknowledge the new order in the medication administration record (MAR).
-New physician orders must be transcribed into the MAR and acknowledged by the nurse.

In an interview conducted on 06/22/22 at 2:30 pm, The Director of Quality confirmed the above findings and the facility's deficient practice.