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Based on interview and record review the facility failed to provide care in a safe setting when the facility's Medications Brought from Home policy was not followed resulting in a patient receiving a possible overdosing of medications. (Patient #1)

Findings include:

Review of the facility provided policy PCPS093 Medications Brought from Home (dated 11/2016) reflected, "Definitions A. 'Patient may take (or use) own medications' - this describes a physician order for the patient's nurse to administer medications obtained from the patient's personal supply. This order may only be carried out if the order is complete and the procedure is followed as outlined below .... A 'Patient may self-administer dose's on the medications' order is not the same as 'Patient may take own medications' order ....
D. Self-administration
1. Unwitnessed self-administration of medications outside of formal, approved programs is prohibited. Rational for the prohibition include:
a. Failing to administer medications in a responsible manner is a violation of the Nursing Practice Act, and a licensed nurse may only document a medication which has been identified and whose administrations he/she has witnessed.
b. If the patient is taking medications that are not documented in the patient's medical record, there is a much higher risk of unidentified drug interactions or adverse drug reactions.
c. Certain medications may interfere with tests/procedures and need to be held; this is difficult to ensure if hospital personnel are not responsible for the administration.
d. Only medications which have been identified administered by nursing will be documented on the Medication Administration Record.

Review of Patient #1's home medications records reflected,
Cardibodpa-levodopa-entacapone (STALEVO) 50-200-200 mg per tablet 3(three)times a day
buPROPion XL (WELLBUTRIN XL) 150 mg 24 hr tablet daily
Carbidopa-levodopa (SINEMET) 25-100 mg per tablet Take 1.5 tablets by mouth 3 (three) times a day
Citalopram (CeleXA) 40 mg tablet Take 40 mg by mouth nightly
Donepezil (ARICEPT) 10 mg tablet Take 10 mg by mouth nightly
Ibuprofen (ADVIL< MOTRIN) 600 mg tablet
Memantine (NAMENDA) 10 mg tablet Take 10 mg by mouth nightly
OLANZapine (ZyPREXA) 15 mg tablet Take 15 mg by mouth nightly
Trazodone (DESYREL) 10 mg tablet Take 400 mg by mouth nightly

Review of the Nursing notes reflected on,
9/2/18 at 6:00 pm, "Patients daughter states that she gave her dad his home Sinemet and Namenda at 1800."
9/4/18 at 11:31 am, "There are orders for pt to take his own home medication, pt took morning medications and night medications this morning, notified attending Dr .... and charge nurse." (resulting in an overdosing)

Review of the Physician's Progress notes dated 9/3/18 reflected," ...Daughter at bedside, patient taking his own home medications ...."

Review of Patient #1's MAR (medication administration records) reflected the home medications had not been listed. The nurses did not know the names of the home medications that were being administered or when they were being administered or who had administered the medications. There was no oversight of the patient's response to the medications for possible adverse reactions with the hospital administered medications.

During an interview on the afternoon of 11/7/18, in the conference room, Staff #12, Pharmacist stated, "We prefer to use the medications in our formulary, but sometimes the families will insist on using their own medications. Usually it's because of cost or it may be a specialized medication we don't have. The medications are sent to the pharmacy, we check them and repackage them. The medications are sent back to the units and placed in the PIXIS." When asked if the pharmacist would check for any contraindications between the hospital administered medications and the home medications Staff #12 stated, "Initially .... They would check the current medication list .... they may not look back at the admission history and physical for home meds ...."

During an interview on the morning of 11/8/18, in the facility conference room, Staff #4, Quality Manager confirmed the facility was not administering the patients home medications and was not recording the medications the patient had been administered from the home medications.

Based on interview and record review the facility's Pharmaceutical Services failed to ensure the safe storage, dispensing, tracking and control of a patient's medications. The facility knowingly allowed the patient's family to provide and administer multiple medications brought from home without the facility's oversite. (Patient #1)

Findings include:

Review of the facility provided policy PCPS093 Medications Brought from Home (dated 11/2016) reflected, "Definitions A. 'Patient may take (or use) own medications' - this describes a physician order for the patient's nurse to administer medications obtained from the patient's personal supply. This order may only be carried out if the order is complete and the procedure is followed as outlined below .... A 'Patient may self-administer dose's on the medications' order is not the same as 'Patient may take own medications' order ....
D. Self-administration
1. Unwitnessed self-administration of medications outside of formal, approved programs is prohibited. Rational for the prohibition include:
a. Failing to administer medications in a responsible manner is a violation of the Nursing Practice Act, and a licensed nurse may only document a medication which has been identified and whose administrations he/she has witnessed.
b. If the patient is taking medications that are not documented in the patient's medical record, there is a much higher risk of unidentified drug interactions or adverse drug reactions.
c. Certain medications may interfere with tests/procedures and need to be held; this is difficult to ensure if hospital personnel are not responsible for the administration.
d. Only medications which have been identified administered by nursing will be documented on the Medication Administration Record.

Review of Patient #1's home medications records reflected,
Cardibodpa-levodopa-entacapone (STALEVO) 50-200-200 mg per tablet 3(three)times a day
buPROPion XL (WELLBUTRIN XL) 150 mg 24 hr tablet daily
Carbidopa-levodopa (SINEMET) 25-100 mg per tablet Take 1.5 tablets by mouth 3 (three) times a day
Citalopram (CeleXA) 40 mg tablet Take 40 mg by mouth nightly
Donepezil (ARICEPT) 10 mg tablet Take 10 mg by mouth nightly
Ibuprofen (ADVIL< MOTRIN) 600 mg tablet
Memantine (NAMENDA) 10 mg tablet Take 10 mg by mouth nightly
OLANZapine (ZyPREXA) 15 mg tablet Take 15 mg by mouth nightly
Trazodone (DESYREL) 10 mg tablet Take 400 mg by mouth nightly

Review of the Nursing notes reflected on,
9/2/18 at 6:00 pm, "Patients daughter states that she gave her dad his home Sinemet and Namenda at 1800."
9/4/18 at 11:31 am, "There are orders for pt to take his own home medication, pt took morning medications and night medications this morning, notified attending Dr .... and charge nurse." (resulting in an overdosing)

Review of the Physician's Progress notes dated 9/3/18 reflected," ...Daughter at bedside, patient taking his own home medications ...."

Review of Patient #1's MAR (medication administration records) reflected the home medications had not been listed. The nurses did not know the names of the home medications that were being administered or when they were being administered or who had administered the medications. There was no oversight of the patient's response to the medications for possible adverse reactions with the hospital administered medications.

During an interview on the afternoon of 11/7/18, in the conference room, Staff #12, Pharmacist stated, "We prefer to use the medications in our formulary, but sometimes the families will insist on using their own medications. Usually it's because of cost or it may be a specialized medication we don't have. The medications are sent to the pharmacy, we check them and repackage them. The medications are sent back to the units and placed in the PIXIS." When asked if the pharmacist would check for any contraindications between the hospital administered medications and the home medications Staff #12 stated, "Initially .... They would check the current medication list .... they may not look back at the admission history and physical for home meds ...."

During an interview on the morning of 11/8/18, in the facility conference room, Staff #4, Quality Manager confirmed the facility was not administering the patients home medications and was not recording the medications the patient had been administered from the home medications.