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Based on document review and interview the facility failed to ensure it's contracted nursing staff followed facility policies/procedures related to medication administration in 1 (Staff N1 (Registered Nurse [RN]) of 5 personnel files reviewed:

Findings include:

1. Review of personnel files for N1 (Registered Nurse [RN] indicated he/she was hired on 11/17/19 per contract with F1.

2. Review of monthly Pyxis Report dated 12/1/19 through 12/31/19 indicated on 12/3/19 at 0045 hours staff N1 pulled morphine 2 mg injection and administered 1 mg morphine injection to patient 1 but didn't waste the remaining 1 mg morphine until 12/3/19 at 2023 hours and at a different Pyxis. On 12/18/19 staff N1 documented wasting hydromorphone 0.5 mg twice at 0146 and 0147 hours (total 1 mg wasted) and documented administering hydromorphone 0.5 mg to patient 2 on 12/18/19 at 0146 hours with only pulling 1 mg of hydromorphone from the Pyxis. On 12/29/19 staff N1 pulled hydromorphone 1 mg from the Pyxis and documented administering 1 mg hydromorphone to patient 3 but documented wasting 0.5 mg of hydromorphone for a total of 1.5 mg hydromorphone from a 1 mg syringe that was pulled. On 12/29/19 staff N1 delayed wasting hydromorphone 0.5 mg for 3 hours post administration to patient 4 and conducted the wasting at a different Pyxis on the unit.

3. Policy/procedure PolicyStat ID: 6186107, Requirements for Outside Agency Personnel Policy, reviewed/revised 4/1/19 indicated on page 2: "5. Agency personnel are subject to all applicable hospital policies and procedures while working at Franciscan Health. Agency staff will comply with local and State Department of Health rules and regulations, regulations of accrediting organizations and all regulatory agencies pertinent to services provided".

4. On 2/19/20 at approximately 1300 hours, staff N6 (Unit Manager 3 East) was interviewed and confirmed staff N1 did not follow the facilities policies/procedures related to medication / narcotic administration.

Based on document review and interview the facility failed to ensure a member of it's nursing staff followed policy/procedure related to administration of narcotic medications in 4 (patient 1, 2, 3 and 4) of 10 medical records (MR) reviewed:

Findings include:

1. Review of patient 1's MR indicated the patient was administered morphine 1 mg per injection on 12/3/19 at 0045 hours per staff N1 (Registered Nurse). Review of December 2019 Pyxis Report indicated staff N1 administered 1 mg morphine injection to patient 1 but didn't waste the remaining 1 mg morphine until the next shift on 12/3/19 at 2023 hours and at a different Pyxis.

2. Review of patient 2's MR indicated the patient was administered hydromorphone 0.5 mg per injection on 12/18/19 at 0146 hours. Review of December 2019 Pyxis Report indicated on 12/18/19 at 0146 and 0147 hours staff N1 documented wasting hydromorphone 0.5 mg (total 1 mg wasted) and documented administering hydromorphone 0.5 mg to patient 2 with only pulling 1 mg of hydromorphone from the Pyxis.

3. Review of patient 3's MR indicated the patient was administered hydromorphone 1 mg per injection on 12/29/19 at 2217 hours. Review of December 2019 Pyxis Report indicated on 12/29/19 at 2217 hours, staff N1 pulled hydromorphone 1 mg from the Pyxis and documented administering 1 mg hydromorphone to patient 3 but documented wasting 0.5 mg of hydromorphone on 12/29/19 at 2217 hours for a total of 1.5 mg hydromorphone from a 1 mg syringe.

4. Review of patient 4's MR indicated the patient was administered hydromorphone 1 mg injection on 12/29/19 at 2327 hours. On 12/29/19, staff N1 delayed wasting hydromorphone 0.5 mg for 3 hours post administration to patient 4 and conducted the wasting at a different Pyxis on the unit.

5. Policy/procedure PolicyStat ID: 5745800, Storage and Administration of Controlled Substances Procedure, reviewed/revised 12/12/18 indicated on page 2: "f. The nurse will discard/waste controlled substances in a manner that prevents diversion. b. Obtaining and Administering Controlled Substances: i. Obtain controlled substance from Pyxis MedStation...6. Verify the beginning count of the controlled substance before any is taken. 7. Discard portion that will not be used, if applicable, and have second nurse witness waste in Pyxis MedStation. ii. Take controlled substance to patient's room. iii. Administer medication using standard medication administration procedure".

6. On 2/19/20 at approximately 1300 hours, staff N6 (Unit Manager 3 East) was interviewed and confirmed staff N1 did not follow the facilities policies/procedures related to medication / narcotic administration.

7. On 2/19/20 at approximately 1315 hours, staff N7 (Manager Pharmacy Services) was interviewed and confirmed medication administration discrepancies related to staff N1 were discovered after reviewing the December 2019 Monthly Pyxis Report.

8. On 2/19/20 at approximately 1330 hours, staff N8 (Chief Nursing Officer) confirmed staff N1 was involved in medication administration discrepancies.

Based on document review and interview the facility failed to ensure it followed it's policies/procedures related to investigation and management of medication administration for facility documents reviewed dated 12/1/19 through 2/19/20.

Findings include:

1. Review of incident report log dated 12/1/19 through 2/19/20 lacked documentation of medication administration incidents related to staff N1.

2. Review of facility administrative documents dated 12/1/19 through 2/19/20 lacked documentation of reporting staff N1's narcotic administration discrepancies to Federal and State agencies as indicated in the facility's policy/procedure, Drug Diversion Prevention, Detection Investigation and Management Policy.

3. Policy/procedure PolicyStat ID: 3194493, Incident Reporting and Investigation Policy, reviewed/revised 9/20/17 indicated: "It is the policy of the hospital and health center to document in an accurate, complete and timely manner, incidents occurring on the hospital and health center property or involving the hospital and health center. This process is used to identify and minimize hazards to employees, patients and visitors by evaluation and analysis of all incidents".

4. Policy/procedure PolicyStat ID: 6812949, Drug Diversion Prevention, Detection Investigation and Management Policy, reviewed/revised 8/21/19 indicated:
A. Page 1: "To provide a written process for detecting and investigating suspected drug diversion in the work place and the management of staff when drug diversion is detected. Franciscan Health will investigate any instances of suspected diversion. Failure to control a controlled substance and falsification of records is a felony which could result in the individual's loss of license, employment and/or legal action. Scope: Any employees, volunteers, contracted staff, vendors, clinical students and medical staff".
B. Page 6: "Reporting...3. The Chief Nursing Officer or Nursing Director is responsible for reporting to the Indiana Board of Nursing and the Attorney General's office any information required by law pertaining to the diversion".
C. Policy Attachment: "Controlled Substance Investigation Checklist: Send fax to Drug Enforcement Agency (DEA) regarding initiation of controlled substance investigation. Should be completed within 24 hours of identifying loss of controlled substance. Notify Indiana Board of Pharmacy that investigation has begun. Search INSPECT for prescription history".

5. On 2/19/20 at approximately 1300 hours, staff N6 (Unit Manager 3 East) was interviewed and confirmed he/she did not complete incident reports related to staff N1's medication administration discrepancies.

6. On 2/19/20 at approximately 1315 hours, staff N7 (Manager Pharmacy Services) confirmed he/she did not complete incident reports related to staff N1's medication administration discrepancies and did not report the discrepancies to any State and/or Federal agencies as indicated in the facility's policy/procedure, Drug Diversion Prevention, Detection Investigation and Management.

7. On 2/19/20 at approximately 1330 hours, staff N8 (Chief Nursing Officer) was interviewed and confirmed staff N1 was involved in medication administration discrepancies. Staff N8 confirmed the facility did not investigate and manage the medication administration discrepancies according to their policy/procedure, Drug Diversion Prevention, Detection Investigation and Management. Staff N8 confirmed State and/or Federal agencies as indicated in the above-mentioned policy/procedure were not contacted. Staff N8 confirmed incident reports were not completed related to the medication administration discrepancies involving staff N1.