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Based on review of medical records (MR) and facility documents and staff interviews (EMP) it was determined that Conemaugh Memorial Medical Center failed to follow adopted policies to ensure the security/storage of patient medications collected on admission to and on discharge from the Adult Behavioral Health Unit in four of 15 medical records (MR1, MR2, MR3 and MR4).


Findings Include:

Review of Conemaugh Memorial Medical Center ... PolicyStat ID: 1649380 ... Last Reviewed: July 2015 ... Policy Area: Behavioral Medicine ... Search, Seizure and Disposition of Drugs, Weapons, and Potentially Harmful Substances ... revealed, "Purpose: To ensure proper use of and removal of all items from the patient's possession which could be life threatening to patient or others. ... Outcome Criteria ... C. Accurate documentation of the disposition of substance and/or object removed. ... Procedure ... B. The Mental Health Procedures Act defines contraband as 'specific property which entails a threat to the 'patients' health and welfare, or to the hospital community.' C. The patient's belongings are searched by staff on admission to the Unit. ... Level I items and belongings considered as potentially harmful and patients cannot have access to these while in the Hospital. ... OTC Meds or Meds from Home ... On the Adult Unit all Level I items go into patient belonging closet, on the Geriatric Unit all Level I items go into the locked closets in each patient room, on the Child/Adolescent Unit all Level I items are locked in the patient's drawers in their rooms. All items are returned to the patient at time of discharge. ... ."

Review of Conemaugh Memorial Medical Center ... PolicyStat ID: 2714976 ... Last Reviewed: August 2016 ... Policy Area: Behavioral Medicine ... Behavioral Medicine Nursing Admission Procedures ... revealed, "... Policy: The RN in charge is responsible for overseeing the admission of all patients to each Unit. This includes the supervision of staff delegated to orient the patient to the Unit, preparation of the environment, and checking of personal belongings brought onto the Unit. ... Equipment ... Valuable Belongings Record ... Points of Emphasis A. Assessment 1. The RN responsible for overseeing the admission of all patients to the Unit this includes orientation to the Unit; preparation of environment, checking personal belongings brought onto the Unit, and makes room assignment and conveys this information as soon as possible to Admissions. Mental Health Technicians [MHT] may also assist in patient orientation. ... 4. After showing the patient to his/her room the RN/MHT escorts the patient to the room where nursing assessment will take place-orienting patient as they go. The following occurs: ... c. Upon explaining the Unit's safety policy, the assigned nursing staff member checks the patient's belongings in his/her presence for contraband items and does not allow the patient to keep such items. The 'Valuables/Essentials Form/Agreement F332' is completed. ... 9. The assigned staff member explains to the patient the necessity for checking belongings, and determines if the patient is able to be responsible for personal property. If the patient is unable to assume accountability for personal property, an itemized list is developed and placed with the belongings in a secured area on th Unit, is sent home with family members, or is locked in the Hospital safe. ... ."

Review of Conemaugh Memorial Medical Center ... PolicyStat ID: 1994562 ... Last Reviewed: September 2016 ... Policy Area: Pharmacy-Clinical ... Home Medication Storage ... revealed, "... Standard: All medications brought into the hospital by patients will be processed according to this policy. Purpose: To ensure the control and safekeeping of the patient's medication while in the hospital. Procedure: 1. Family members of patients bringing in home medications are asked to take the medications back home. 2. If unable to send medications home, the meds are reviewed and entered into Clinical History, Home Med List by nursing. 3. The Home Medication Sheet is printed. The disposition of each medication brought in from home is indicated on this sheet via checking the appropriate column. 4. The patient and the nurse will sign the form and place it in a white security bag, located underneath the medication return bin, and the patient will witness the sealing of the bag. 5. The serial number tab form the security bag is removed and stapled to the valuables sheet and the floor designation and patient name is written on the sealed bag. 6. A neon green reminder sticker is placed on the front of the chart indicating the patient has home meds stored in the pharmacy. 7. The security bag is placed in the pharmacy med return bin for technician pick-up. 8. Upon technician pick-up, the Log In portion of the Home Medication Log, located with the narcotic sheets, will be completed by nursing and pharmacy. 9. The Security bag will be securely stored in the pharmacy during the patient's stay. 10. Potential discharges will be communicated to the unit clerk who will complete the Pharmacy/Nursing Communication sheet and fax it to the pharmacy if the patient has medications stored. 11. In the event of a patient death, nursing will notify the pharmacy via phone and document the death on the Home Medication Log. Pharmacy is then obligated to destroy the medications. 12. The technician will deliver the Security bag on the next round and the Log Out portion of the Home Medication Log will be completed. 13. In the event that the discharged patient has been transferred, the Home Medication Log on the transferred floor will be completed as to Patient Name, Date, Bag Number, and Log Out Information. 14. If Nursing presents at pharmacy window for a med pickup and has the serial number tab, a log will be completed to record the disposition of the med from the pharmacy to Nursing. 15. Upon discharge, the nurse will open the bag with the patient present, remove the list and review the medications with the patient. Any home meds used during the stay will be retrieved. 16. The Home Medication Sheet will be signed by the nurse and the patient and placed in the chart. 17. Completed Homed Medication Logs are sent to the Pharmacy. 18. Medications still stored in the pharmacy thirty days after discharge will be destroyed."

1) An interview was conducted with EMP5 on November 3, 2016, at approximately 10:00 AM. "They are admitted through the ED and come with their belongings. The belongings are handed over to the staff. The MHT [mental health technician] and RN go through them with the patient and any meds are handed over to the nurse and are documented. I check and chart 'Bottle X' with the appropriate amount of pills. They are put in the security bag and sealed. I take the label from the bag and attach it to the clothing sheet and log them out. On the bag I write the name and number of the meds, secure the bag, put it in the red bin and then someone from Pharmacy comes to pick them up. The clothing sheet is where the documentation is that the meds were sent to Pharmacy. ... ."

2) An interview was conducted with EMP4 on November 3, 2016, at approximately 9:45 AM. EMP4 revealed, "... On discharge every item is reviewed on the belongings list and given back to the patient. ... ."

3) An interview was conducted with EMP6 on November 3, 2016, at approximately 10:00 AM. "I go through the belongings and give the meds to the nurse. When they are discharged, I pull stuff from the safe and get the belongings. I show them exactly what is in there and make sure that we sign with them. We put the med bag in too and secure the whole thing in a locked closet until the patient is ready to leave."

4) Review of Memorial Medical Center Home Medication Log for the Adult Behavioral Health Unit dated August 4, 2016, through October 25, 2016, was conducted. The Log revealed 52 entries, some with multiple entries for the same patient. The Log revealed information to be included: Date, Patient Name, Bag #, Log In Nursing, Pharmacy, Log Out Nursing, Pharmacy. Twenty-two of the 52 entries were incompletely logged as there were blank areas noted in the "Log In Nursing, Pharmacy, Log Out Nursing, Pharmacy" section.

5) MR1 revealed, "Valuables/Essentials Form/Agreement ... Section A ... Retained on Admission ... Discharge ... Patient/Decision maker Designee Signature certifies that I am taking with me the items on this list Patient, Decision Maker or Designee Signature ... ." The form was signed by the patient/designee on admission and discharge. MR1 revealed no documented evidence of home medications listed on the Valuables/Essentials Form/Agreement. MR1 revealed one Medication Bag receipt that verified the patient had medications collected. The Home Medication Log revealed documented evidence that Nursing and Pharmacy logged in on October 1, 2016, however, only Pharmacy logged out on October 6, 2016. EMP4 confirmed the above findings.

6) Review of MR2 revealed, "Valuables/Essentials Form/Agreement ... Section A ... Retained on Admission ... Discharge ... Patient/Decision maker Designee Signature certifies that I am taking with me the items on this list Patient, Decision Maker or Designee Signature ... ." The form was signed by the patient/designee on admission and discharge. MR2 revealed no documented evidence of home medications listed on the Valuables/Essentials Form/Agreement. MR2 revealed three Medication Bag receipts that verified the patient had medications collected. The Home Medication Log revealed documented evidence that Nursing and Pharmacy logged in on September 28, 2016, and Nursing and Pharmacy logged out on September 30, 2016. EMP4 confirmed the above findings.

7) Review of MR3 revealed, "Valuables/Essentials Form/Agreement ... Section A ... Retained on Admission ... Discharge ... Patient/Decision maker Designee Signature certifies that I am taking with me the items on this list Patient, Decision Maker or Designee Signature ... ." The form was signed by the patient/designee on admission and discharge. MR3 revealed no documented evidence of home medications listed on the Valuables/Essentials Form/Agreement. MR3 revealed one Medication Bag receipt that verified the patient had medications collected. The Home Medication Log revealed documented evidence that Nursing and Pharmacy logged in on October 4, 2016, however, only Pharmacy logged out on October 5, 2016. EMP4 confirmed the above findings.

8) Review of MR4 revealed no documented evidence of the "Valuables/Essentials Form/Agreement" MR4 revealed one Medication Bag receipt that verified the patient had medications collected. The Home Medication Log revealed documented evidence that Nursing and Pharmacy logged in on September 20, 2016, however, only Pharmacy logged out on September 22, 2016. EMP4 confirmed the above findings.

Based on a review of medical records (MR) and facility documents and interview with facility staff (EMP), it was determined that Conemaugh Memorial Medical Center failed to follow adopted policies to ensure the security/storage of patients home medications collected on admission to and returned to the patient on discharge from the Adult Behavioral Health Unit in four of fifteen medical records (MR1, MR2, MR3 and MR4).


Findings Include:

Review of Conemaugh Memorial Medical Center ... PolicyStat ID: 1649380 ... Last Reviewed: July 2015 ... Policy Area: Behavioral Medicine ... Search, Seizure and Disposition of Drugs, Weapons, and Potentially Harmful Substances ... revealed, "Purpose: To ensure proper use of and removal of all items from the patient's possession which could be life threatening to patient or others. ... Outcome Criteria ... C. Accurate documentation of the disposition of substance and/or object removed. ... Procedure ... B. The Mental Health Procedures Act defines contraband as 'specific property which entails a threat to the 'patients' health and welfare, or to the hospital community.' C. The patient's belongings are searched by staff on admission to the Unit. ... Level I items and belongings considered as potentially harmful and patients cannot have access to these while in the Hospital. ... OTC Meds or Meds from Home ... On the Adult Unit all Level I items go into patient belonging closet, on the Geriatric Unit all Level I items go into the locked closets in each patient room, on the Child/Adolescent Unit all Level I items are locked in the patient's drawers in their rooms. All items are returned to the patient at time of discharge. ... ."

Review of Conemaugh Memorial Medical Center ... PolicyStat ID: 2714976 ... Last Reviewed: August 2016 ... Policy Area: Behavioral Medicine ... Behavioral Medicine Nursing Admission Procedures ... revealed, "... Policy: The RN in charge is responsible for overseeing the admission of all patients to each unit. This includes the supervision of staff delegated to orient the patient to the Unit, preparation of the environment, and checking of personal belongings brought onto the Unit. ... Equipment ... Valuable Belongings Record ... Points of Emphasis A. Assessment 1. The RN responsible for overseeing the admission of all patients to the Unit this includes orientation to the Unit; preparation of environment, checking personal belongings brought onto the Unit, and makes room assignment and conveys this information as soon as possible to Admissions. Mental Health Technicians [MHT] may also assist in patient orientation. ... 4. After showing the patient to his/her room the RN/MHT escorts the patient to the room where nursing assessment will take place-orienting patient as they go. The following occurs: ... c. Upon explaining the Unit's safety policy, the assigned nursing staff member checks the patient's belongings in his/her presence for contraband items and does not allow the patient to keep such items. The 'Valuables/Essentials Form/Agreement F332' is completed. ... 9. The assigned staff member explains to the patient the necessity for checking belongings, and determines if the patient is able to be responsible for personal property. If the patient is unable to assume accountability for personal property, an itemized list is developed and placed with the belongings in a secured area on th Unit, is sent home with family members, or is locked in the Hospital safe. ... ."

Review of Conemaugh Memorial Medical Center ... PolicyStat ID: 1994562 ... Last Reviewed: September 2016 ... Policy Area: Pharmacy-Clinical ... Home Medication Storage ... revealed, "... Standard: All medications brought into the hospital by patients will be processed according to this policy. Purpose: To ensure the control and safekeeping of the patient's medication while in the hospital. Procedure: 1. Family members of patients bringing in home medications are asked to take the medications back home. 2. If unable to send medications home, the meds are reviewed and entered into Clinical History, Home Med List by nursing. 3. The Home Medication Sheet is printed. The disposition of each medication brought in from home is indicated on this sheet via checking the appropriate column. 4. The patient and the nurse will sign the form and place it in a white security bag, located underneath the medication return bin, and the patient will witness the sealing of the bag. 5. The serial number tab form the security bag is removed and stapled to the valuables sheet and the floor designation and patient name is written on the sealed bag. 6. A neon green reminder sticker is placed on the front of the chart indicating the patient has home meds stored in the pharmacy. 7. The security bag is placed in the pharmacy med return bin for technician pick-up. 8. Upon technician pick-up, the Log In portion of the Home Medication Log, located with the narcotic sheets, will be completed by Nursing and Pharmacy. 9. The Security bag will be securely stored in the Pharmacy during the patient's stay. 10. Potential discharges will be communicated to the Unit Clerk who will complete the Pharmacy/Nursing Communication sheet and fax it to the Pharmacy if the patient has medications stored. 11. In the event of a patient death, Nursing will notify the Pharmacy via phone and document the death on the Home Medication Log. Pharmacy is then obligated to destroy the medications. 12. The Technician will deliver the Security bag on the next round and the Log Out portion of the Home Medication Log will be completed. 13. In the event that the discharged patient has been transferred, the Home Medication Log on the transferred floor will be completed as to Patient Name, Date, Bag Number, and Log Out Information. 14. If Nursing presents at Pharmacy window for a med pickup and has the serial number tab, a log will be completed to record the disposition of the med from the pharmacy to Nursing. 15. Upon discharge, the nurse will open the bag with the patient present, remove the list and review the medications with the patient. Any home meds used during the stay will be retrieved. 16. The Home Medication Sheet will be signed by the nurse and the patient and placed in the chart. 17. Completed Homed Medication Logs are sent to the Pharmacy. 18. Medications still stored in the Pharmacy thirty days after discharge will be destroyed."

1) An interview was conducted with EMP5 on November 3, 2016, at approximately 10:00 AM. "They are admitted through the ED and come with their belongings. The belongings are handed over to the staff. The MHT [mental health technician] and RN go through them with the patient and any meds are handed over to the nurse and are documented. I check and chart 'Bottle X' with the appropriate amount of pills. They are put in the security bag and sealed. I take the label from the bag and attach it to the clothing sheet and log them out. On the bag I write the name and number of the meds, secure the bag, put it in the red bin and then someone from Pharmacy comes to pick them up. The clothing sheet is where the documentation is that the meds were sent to Pharmacy. ... ."

2) Review of Memorial Medical Center Home Medication Log for the Adult Behavioral Health Unit dated August 4, 2016, through October 25, 2016, was conducted. The Log revealed 52 entries, some with multiple entries for the same patient. The Log revealed information to be included: Date, Patient Name, Bag #, Log In Nursing, Pharmacy, Log Out Nursing, Pharmacy. Twenty-two of the 52 entries were incompletely logged as there were blank areas noted in the "Log In Nursing, Pharmacy, Log Out Nursing, Pharmacy" section.

3) Review of MR1 revealed, "Valuables/Essentials Form/Agreement ... Section A ... Retained on Admission ... Discharge ... Patient/Decision maker Designee Signature certifies that I am taking with me the items on this list Patient, Decision Maker or Designee Signature ... ." The form was signed by the patient/designee on admission and discharge. MR1 revealed no documented evidence of home medications listed on the Valuables/Essentials Form/Agreement. MR1 revealed one Medication Bag receipt that verified the patient had medications collected. The Home Medication Log revealed documented evidence that Nursing and Pharmacy logged in on October 1, 2016, however, only Pharmacy logged out on October 6, 2016. EMP4 confirmed the above findings.

4) Review of MR2 revealed, "Valuables/Essentials Form/Agreement ... Section A ... Retained on Admission ... Discharge ... Patient/Decision maker Designee Signature certifies that I am taking with me the items on this list Patient, Decision Maker or Designee Signature ... ." The form was signed by the patient/designee on admission and discharge. MR2 revealed no documented evidence of home medications listed on the Valuables/Essentials Form/Agreement. MR2 revealed three Medication Bag receipts that verified the patient had medications collected. The Home Medication Log revealed documented evidence that Nursing and Pharmacy logged in on September 28, 2016, and Nursing and Pharmacy logged out on September 30, 2016. EMP4 confirmed the above findings.

5) Review of MR3 revealed, "Valuables/Essentials Form/Agreement ... Section A ... Retained on Admission ... Discharge ... Patient/Decision maker Designee Signature certifies that I am taking with me the items on this list Patient, Decision Maker or Designee Signature ... ." The form was signed by the patient/designee on admission and discharge. MR3 revealed no documented evidence of home medications listed on the Valuables/Essentials Form/Agreement. MR3 revealed one Medication Bag receipt that verified the patient had medications collected. The Home Medication Log revealed documented evidence that Nursing and Pharmacy logged in on October 4, 2016, however, only Pharmacy logged out on October 5, 2016. EMP4 confirmed the above findings.

6) Review of MR4 revealed no documented evidence of the "Valuables/Essentials Form/Agreement" MR4 revealed one Medication Bag receipt that verified the patient had medications collected. The Home Medication Log revealed documented evidence that Nursing and Pharmacy logged in on September 20, 2016, however, only Pharmacy logged out on September 22, 2016. EMP4 confirmed the above findings.