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Based on review of the medical record, Medication Administration Record [MAR] and staff interviews, for one Patient (#8) out of a total sample of 11, the Attending Psychiatrist failed to order Patient # 8's regularly prescribed medications that included prednisone, methotrexate and glipizide, which resulted in the patient not receiving those medications during a 12 day hospitalization.

Findings include:

Patent #8 was admitted to the psychiatric unit for sexual behaviors and combativeness at the Hospital on 11/4/11. Patient # 8's medical history included dementia, diabetes and rheumatoid arthritis.

Review of Patient #8's form for Current Home Medication List indicated that prednisone, methotrexate and glipizide were prescribed medications that Patient #8 received at his/her nursing home and the Attending Psychiatrist reconciled, timed and dated the form on 11/7/11 at 6:00 P.M.

Review of Physician Orders and Medication Summary records dated 11/4/11-11/16/11 indicated that the Attending Psychiatrist did not write orders for prednisone, methotrexate and glipizide.

Review of the Hospital's policy and procedure for Medication Reconciliation indicated that a list of current home medications shall be documented as soon as possible during the intake process, but no later than 24 hours after admission. The policy/procedure indicated the unit secretary will fax the Current Home Medication List to the Pharmacy once the RN signs the form verifying that the list was reviewed with the patient/family.

The Patient Care Director for In/Out Patient Psychiatry was interviewed in person on 12/14/11 at 11:25 A.M. and 12:20 P.M. The Patient Care Director said he received a complaint from the nursing home indicating that Patient #8 was not receiving prednisone, methotrexate and glipizide during hospitalization.

The Risk Manager was interviewed throughout the on-site investigation. The Risk Manager said she reviewed Patient #8's medical record and compared the medical reconciliation form and the computerized provider order entry (CPOE) form and concluded the Patient's regularly prescribed medications were not ordered for Patient #8.

The Vice President [VP] for Medical Affairs was interviewed on 12/13/11 at 7:70 AM and on 12/15/11 at 12:15 P.M. The VP said that he discussed the care provided to Patient #8 with the Chief Executive Officer and the Attending Psychiatrist. The VP said that a medical peer review process was conducted and the recommendation for action (as outline in Article 4., Section 4.3 Summary Suspension and Article 5 Hearing and Appellate Review Procedure in the Medical Staff By-Law) was provided to the Attending Psychiatrist and he was waiting for the Attending Psychiatrist's response to the recommendation..

Based on observations, record review, interviews and review of Hospital policy, the Hospital failed to ensure that accepted standards of nursing practice were incorporated in the Hospital's policies/procedures for the administration of medications.

Findings include:

1) Observations made in the Emergency Department on 12/13/11 at 9:45 to 9:55 A.M. included a medication pass to Patient #2. Patient #2 was administered an oral antibiotic at 9:55 A.M. by an Emergency Department [ED] nurse using the 5 rights of medication administration

2) Review of the Hospital policy titled Medication Administration Policy did not indicate that the nurse will administer medications to patients using the 5 rights of medication administration.
3) According to the The U.S. Department of Health and Human Services the five rights, as an important goal for safe medication practices include: 1) the right patient, 2) the right drug, 3) the right dose, 4) the right route and 5) the right time. The 5 right's form the foundation for safe medication administration and error reduction.
4) The Risk Manager and the Patient Care Director of the ED/Intensive Care Unit reviewed the Hospital's medication administration policy with this Surveyor and they did not identify the 5 right's in the policy/procedure.

Based on review of the medical record and interviews, the Hospital failed to ensure that the disclosure and discussion regarding a medication error that occurred on 11/7/11 was documented in 1 of 11 patient records reviewed, for Patient #1, as required by Hospital policy.

Findings include:

Review of Patient#1's medical record dated 11/7/11 indicated that ED Patient #1 received Vecuronium instead of the prescribed Vancomycin. ED record documentation indicated that Patient #1's primary language was not English

The Risk Manager was interviewed intermittently during the on-site investigation. The Risk Manager said the error was disclosed to the Patient #1's family shortly after the error occurred.

The Patient Care Director of the ED/ICU was interviewed intermittently during the on-site investigation. The Patient Care Director said he discussed the medication error with Patient #1's family. Patient #1's family requested that Patient #1 be informed of the medication error after he/she was removed from mechanical ventilation. The Patient Care Director said he discussed the medication error with Patient #1 and a family member with an interpreter.

Review of the Hospital's policy/procedure regarding Communication of Unanticipated Outcomes indicated that the disclosure discussion should be documented in the patient's medical record. The documentation should include a brief summary of the discussion, when the discussion occurred and who was present during the discussion.

Review of patient care notes in Patient #1's medical record dated 11/7/11-11/11/11 indicated that the discussion regarding the medication error was not documented in Patient #1's record as required per hospital policy.

Based on a review of the completed monthly Pharmacy Floor Inspections and the Floor Inspections log and interviews, the Hospital failed to ensure that the patient care medication areas were inspected on a regular basis.

Findings include:

1) According to the Pharmacy Floor Inspections Log, less than 50% of monthly patient care area inspections were checked off as having been completed.

2) A review of the actual Floor Inspection forms for January through June of 2011 revealed that 15 inspection forms, listed on the Log as having been completed, were not in the notebook. [Monthly inspections are an opportunity to ensure that special labeling and packaging are being done throughout the institution.]

Based on a review of the completed monthly Pharmacy Floor Inspections and the Floor Inspections log and interviews, the Hospital failed to ensure that the patient care medication areas were inspected on a regular basis.

Findings include:

1) According to the Pharmacy Floor Inspections Log, less than 50% of monthly patient care area inspections were checked off as having been completed.

2) A review of the actual Floor Inspection forms for January through June of 2011 revealed that 15 inspection forms, listed on the Log as having been completed, were not in the notebook. [Monthly inspections are an opportunity to ensure that special labeling and packaging are being done throughout the institution.]