HospitalInspections.org

Based on a review of documents and interviews with staff, the medical staff was not accountable to the governing body for the quality of the medical care provided to the patients.

Findings were:

A review of facility policy #III-E.29 titled INSOMNIA PROTOCOL states, in part, " POLICY STATEMENT: To establish consistency in prescribing patterns and to monitor the need and effectiveness of the short-term use of hypnosedative agents for patient in the hospital (excludes the Pavilion) ...2. Prescriber Responsibilities: ...a. Prescriber will initiate appropriate hypnosedative agent to be administered from the following available:
? Zolpidem 5 mg
? Temazepam 15 mg (<65 years old)
? Temazepam 7.5 mg (>65 years old)

4. Pharmacist Responsibilities: ...c. The pharmacist will be responsible for initiating the lowest dose of the agent prescribed by the physician, i.e., prescription written for " zolpidem 10 mg PO QHS PRN insomnia will be auto-substituted for " zolpidem 5 mg PO x 1 dose, may repeat an additional 5 mg PO x 1 in 30 minutes if needed for insomnia " ; ...Auto-Substitutions: Orders written for the following hypnosedatives (PRN insomnia) will be substituted accordingly:
? zolpidem a 5 mg PO HS PRN insomnia: may repeat if necessary in 30 minutes (if age <65 years old)
? zolpidem a 5 mg PO HS PRN insomnia (if age > or equal to 65 years old)

A review of NWT Medical Executive Committee meeting minutes (8-9-11) revealed, in part, the following documentation:

" Minutes from the July 26th PTIC meeting were reviewed. The following was highlighted:
? Insomnia Protocol - Conclusions/Recommendations/Action: The Medical Executive Committee reviewed the Insomnia Protocol and approved as submitted with no further action. "

In an interview with staff #7 on 7-3-12, he was unable to provide any documentation to show that the protocol had been communicated with staff #10.

The above was confirmed in an interview with the Chief Executive Officer, the Chief Nursing Officer and other administrative staff during the afternoon of 7-5-12 in the facility conference room.