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Based on observation, interview, record review and policy review, staff failed to follow the hospital's policy to ensure:
- Staff verified medications prior to administration for all patients cared for in the Emergency Department (ED).
- The safe administration of high alert medications (drugs that bear a heightened risk of causing significant patient harm when they are used in error) for one current patient (#1) of one patient who received a high alert medication.
- ED nurses administered medications after the medication order was reviewed and approved by the pharmacist for two current patients (#9 and #16) of two current patients observed. The hospital census was 12, including swing beds.

These failed practices resulted in a systemic failure and noncompliance with 42 CFR Subpar F 485.635 Condition of Participation (CoP): Provision of Services.

Please refer to C-1049.

Based on observation, interview, record review and policy review, staff failed to follow the hospital's policy to ensure:
- Staff verified medications prior to administration for all patients cared for in the Emergency Department (ED).
- The safe administration of high alert medications (drugs that bear a heightened risk of causing significant patient harm when they are used in error) for one current patient (#1) of one patient who received a high alert medication.
- ED nurses administered medications after the medication order was reviewed and approved by the pharmacist for two current patients (#9 and #16) of two current patients observed.

Findings included:

Review of the hospital's undated policy, "Medication Safety High-Alert Medications," showed:
- High risk or high alert medications were drugs involved in a high percentage of medication errors.
- High risk drugs were to be stored separately from each other to avoid errors in drug selection. Different brands of insulin (a hormone that regulates the amount of sugar in the blood) would be stored separately.
- Hospital committees developed strategies designed to promote the safe and effective use of high alert drugs.
- A double check system should be implemented for the nursing service for preparing a dose of insulin.

Review of the hospital's undated policy, "Insulin Administration," showed:
- Prior to a dose of insulin being administered, a separate independent double check must be performed by two nurses.
- The two nurses who performed the independent double check, must individually confirm/verify all components of the rights of medication administration.
- The rights of medication administration included right patient; right drug; right dose; right route; and right time.
- Each nurse independently reviewed the prescribed insulin order and calculations, used to determine the dose of insulin to be administered.
- The two nurses' findings were to be compared to the other's, prior to the insulin dose being administered.
- The insulin dose could be administered if both nurse's finding matched.
- The process was stopped and any identified issues resolved, prior to the insulin dose being administered.

Review of the hospital's policy, "Drug Preparation/ Dispensing," dated 03/08/25, showed:
- Drug preparation and dispensing was restricted to a licensed pharmacist or a designee under the direct supervision of a pharmacist.
- The pharmacist was to review the appropriateness of all medication orders for drugs to be dispensed in the hospital. That included removal of medications from floor stock or from an automated medication storage distribution machine.
- A pharmacist or authorized personnel under the direction of the pharmacist will fill and label containers from which drugs are to be distributed or dispensed.
- In rare clinical situations such as an emergency when time does not permit a pharmacist's review, a nurse may telephone the pharmacist for a new order and approval to administer a drug.
- When an order was written when the pharmacy was closed and in the absence of a pharmacist, a healthcare professional determined to be qualified by the hospital will review the medication order.

Observation with concurrent interview, on the medical-surgical floor, on 10/27/25 at 12:40 PM, showed:
- Patient #1's blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person's normal range for a patient with diabetes [a disease that affects how the body produces or uses blood sugar and can cause poor healing] is 80 to 180) was 353. That blood glucose value required 12 units of Novolog (a rapid-acting blood glucose lowering medication) per the physician's orders.
- Staff G, Registered Nurse (RN), drew up 12 units of Novolog from a multi-dose vial.
- Staff G checked Patient's #1's medical record in the patient's room and verified the correct patient and correct dose. The patient and the medication were not scanned prior to administration.
- There was no second nurse verification prior to the high alert medication being administered.
- Staff G stated that insulin was unable to be scanned and she usually had a second nurse verify the dose prior to administering it, but the electronic medical record (EMR) did not require a witness to verify the medication administered and insulin could not be scanned prior to being administered.

Observation with concurrent interviews on 10/28/25 at 9:40 AM, showed:
- Staff U, RN, drew up and administered 15 units of Lantus (a long-acting blood glucose lowering medication) from a multi-dose vial in the medication room for Patient #1.
- The medication was not scanned nor was a witness obtained to verify the order, medication or dose administered.
- Staff U stated that she looked at the patient's orders before she entered the medication room and remembered that 15 units were ordered and typed that amount into the automated medication storage distribution machine. Insulin was not a medication that was set up to be scanned and she triple checked it because it made her nervous.

During an interview on 10/29/25 at 3:27 PM, Staff L, Pharmacy Director, stated that he didn't believe insulin was a medication which required a witness to verify the dose administered prior to administration. The hospital had a high alert medication list that they would be reviewing to ensure a process would be set-up for high alert medication to require a barcode scan and witness verification prior to the dose being administered.

Observation and concurrent interview, in the ED, on 10/28/25 at 1:25 PM, showed:
- Staff W, RN, received a verbal order from the physician to administer a dose of Meclizine (a medication used to treat motion sickness and vertigo [dizziness or lightheadedness]) and lorazepam (a medication used to treat anxiety or sleep difficulty) to Patient #9.
- Immediately after the verbal order was received, Staff W removed the oral medication from the automated medication storage distribution machine and administered it to Patient #9.
- The patient's name and date of birth were verified verbally but neither the patient nor medication was scanned.
- Staff W stated that she was unsure if the order had been placed into the electronic health record yet. Both physicians and nurses entered verbal orders. There was no way for staff to scan patient medications in the ED.

Observation in the ED on 10/29/25 at 11:50 AM, showed:
- Staff Y, Charge Nurse, received a verbal order from the physician for Patient #16 to receive a dose of aspirin (blood thinner that can also treat pain, fever, headache and inflammation).
- Immediately after the verbal order was received, Staff Y removed the medication from the automated medication storage distribution machine. The medication was not reviewed or approved by a pharmacist.
- Staff Y administered the medication to Patient #16, then entered the verbal order and charted the medication as administered.

During an interview on 10/28/25 at 3:00 PM, Staff A, ED and Medical-Surgical Nurse Manger, stated that:
- ED patients did not have a patient specific medication profile, as ordered by the ED provider, set-up within their automated medication storage distribution machine.
- When an ED nurse removed medications for an ED patient, every medication stocked in the medication storage distribution machine could be removed.
- She expected the ED nurses to enter a verbal medication order into the computer prior to the medication being removed and administered.
- Medications should not be removed and administered without an order being placed in the computer, unless it was an emergency.
- They currently were unable to scan medication in the ED.

During an interview on 10/29/25 at 4:22 PM, Staff O, Chief Nursing Officer (CNO), stated that she expected all staff to follow the hospital's policies and procedures, at all times.


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