HospitalInspections.org

Based on medical record review and review of the hospital's policies and procedures, it was determined that in one of five records reviewed, Record # 2, the hospital failed to provide care according to acceptable standards of care in a safe setting.

Findings:
1. The St. Charles Health System had a procedure titled: "Use of Patient's Own Medications," Document Number: W07003, Last Updated 10/25/2011 that stated under SCMS [St Charles Medical Center]-Redmond:
"A. All personnel medications will be placed in a valuables envelope with the name and strength of each medication transcribed on it.
B. The valuables envelope is brought to the pharmacy for storage. A valuables receipt will remain in the nursing notes section of the patient's chart.
C. Upon discharge of the patient, the discharging nurse will remove the valuables envelope receipt from the chart and present it to pharmacy for the valuables envelope containing medications.
D. After the patient signs the valuables envelope receipt, the nurse shall send the medications home with the patient.
E. Unclaimed, personal medications remaining in the pharmacy 30 days after a patient's discharge from the hospital will be destroyed. Personal medications remaining in the pharmacy at the time of that patient's death will be destroyed."

2. Review of the "St. Charles Redmond, Redmond ED Triage Report revealed that Patient #2 was seen in the ED on 02/15/2014 at 1206. The "Patient Narrative" revealed: "States approx [approximately] 0400 today took multiple different meds [medications] to help [him/her] sleep. Pt. has a med organizer and took 5 days of various meds,[sic] pt also is vague an poor unreliable historian. Has a lg [large] bag of meds with multiple empty bottles. Pt denies taking any of those meds, when asked if depressed states yes...." At 1505, the patient was admitted to the ICU.

Review of the "Progress Note Report" for "02/15/2014 12:00 Through 02/28/2014 03:47" revealed that on 02/18/2014, Patient #2's status was upgraded and he/she was moved from the ICU to a medical floor. On 02/23/2014 at 1846, the patient was noted to be "anxious and escalating, took off [his/her] oxygen and used [his/her] inhalers in [his/her] belongings. These are medications [he/she] had ordered but [he/she] took them while this RN was going to get [his/her] inhaler. [He/She] took an extra dose of advair [antiasthmatic]." At 2214, Patient #2 was found to be unresponsive and a rapid response was called. At 2330, Patient #2 was re-admitted to the ICU.

The physician's "Discharge Summary"dictated on 02/27/2014 at 0854 stated: "On the evening of 02/23/2014, the patient actually was found unresponsive again in his room. A suicide note was found and it looked like the patient had overdosed on nitrates and other medications that were in his room , these were [his/her] medications that were still in there."

Hospital staff failed to follow the existing policy and Procedure and remove the patient's medication from the patient's belongings when the patient was admitted.

Based on the review of medical records, it was determined that in one of five medical records of individuals who received services at the hospital, Patient # 2, the hospital failed to ensure that all drugs were administered in accordance with Federal and State laws and accepted standards of practice.

Findings:

See the deficiency cited at A104 wherein hospital nursing staff failed to remove the patient's access to the patient's own medications at the time of admission as required by the hospital's policy and procedure. This patient, admitted for treatment for an overdose, overdosed for a second time by taking those available medications.