HospitalInspections.org

Based on document review, medical record review, and staff interviews, it was revealed that the facility failed to follow their policy on "Patient's Own Medications" in one (1) out of ten (10) Patients, Patient #1. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

A review was conducted of a policy, "Patient's Own Medication," last reviewed 04/18/24. The policy states in part, "...Procedure:...2. If the patient's medications are to be sent to Pharmacy for storage, they must first be inventoried and sealed in a medication security bag. A. Nursing will search and remove patient Med bag from Omnicell. i. The primary nurse will inventory the medications in the presence of the patient and record on the patient medication receipt. The inventory sheet will be signed by the primary nurse and patient, or designee. 1. If a medication is a controlled substance, it will be double counted by the primary nurse in the presence of second nurse and the patient. The form needs to be signed by all three (3) present...iv. The bag will be sealed in the presence of the patient, or designee.."

A medical record review was conducted for Patient #1. The Patient presented to the facility for surgery for a venous access Port (port-a-catheter) and a jejunostomy (j-tube) placement after a diagnosis of Esophageal Cancer, stage IIIA.
A "Patient Medication Receipt" dated on 01/09/25 with no time listed states the following "Name of medications: Acetaminophen 500 (five hundred) mg (milligram)tablets and Buprenorphine 2 (two) mg/0.5 (zero point five) mg tablets - quantity (for controlled substances) 19 (nineteen). Nurse and patient or designee must sign when received and returned. Date received: 1/9/25. Nurse signature: [Staff #10]. Second nurse witness for controlled substances: [Staff #18]. Patient or designee signature: (no signature listed)."

May it be noted; Staff #18 is not a Nurse.

Staff #15 demonstrated the process for obtaining a Patient's own medication bag from the Omnicell to take to the pharmacy. Staff #15 explained, "If the medication is a controlled substance, the medicine must be counted by two (2) RN (Registered Nurses) at the Patient's bedside, signed by both nurses and the patient, and sealed in front of the patient. The bag is then hand delivered to the pharmacy."

An interview was conducted with Staff #13 on 03/04/25 at 12:56 p.m. When asked about the patient medication receipt, Staff #13 states, "Typically two (2) Registered Nurses have to sign the receipt. The nurse taking care of the patient, and a second one (1) as a witness. I do not know why the document was not signed by a second Registered Nurse and the pharmacy technician signed it instead. I will discuss it with [Staff #10] and see if [he/she] remembers."

An additional interview was conducted with Staff #13 via telephone on 03/04/25 at 1:45 p.m. Staff #13 states, "I discussed the patient medication receipt and showed it to [Staff #10]. [He/She] does not remember what happened. [He/She] does not even remember filling out the sheet. [He/She] does not recall why the pharmacy technician signed as a second witness. The pharmacy technician is not supposed to be the second witness; the sheet itself says RN."

An interview was conducted with Staff #14 on 03/04/25 at 2:33 p.m. Regarding the "Patient Medication Receipt" staff #13 states, "The process is that if the medication is a controlled substance, the nurse counts it in front of the patient. Another registered nurse is there to witness the count and signs as a witness, and then the patient signs the form and the envelope is sealed in front of the patient. They then bring it to the pharmacy and Pharmacy signs in. Suboxone is a controlled substance. The policy says two (2) nurses must sign for controlled substances. The second signature on the sheet is a pharmacy technician."