HospitalInspections.org

Based on policy review, grievance review, medical record review, and staff interview, the hospital nursing staff left medication unattended in a patient's room in 1 of 1 patient reviewed. (Patient #3).

Findings included:

Review of the hospital policy titled Standardize Processes for Transporting Medication from the ADC to the Patient's Bedside, last reviewed 04/2021 revealed "...I. PURPOSE: 1.1 A process should be developed that reduces the risk of medications being administered to the wrong patient at the wrong time during the transportation of the medications from the ADC (Automatic Dispensing Cabinet) to the patient...II. POLICY: 2.1 Transport medications in their original unit-dose package. Practitioners need the ability to clearly identify the patient's medications at the time of administration for the purpose of bar-code point-of-care systems, last minute check of medications while at the bedside, and patient education..."

Review of the hospital policy titled Security of Staff and Drugs, last reviewed 04/2021 revealed "...10. REQUIREMENT FOR LOCKABLE STORAGE...10.1 Lockable storage units or lockable drug carts, if necessary, shall be provided for drug storage areas throughout the facility. Drugs shall be kept in locked storage or be inaccessible to patients, visitors, and unauthorized staff ..."

Review on 02/07/2023 of the Grievance Report dated 02/02/2023 at 0648 via hospital website online portal was placed by Patient #3's daughter (named) revealed "...3. 01/21/2023 noon meds (medication) and Dilaudid (narcotic pain medication for severe pain) was left on the sink, all unattended." Review of the Grievance Report revealed photographs of 2 unlabeled syringes beside a medication cup with an oblong capsule, and circular tablet in a cup. Review revealed an acknowledgement receipt of the grievance had been sent out on 02/06/2023, and the grievance was entered into the grievance system on 02/06/2023.

Closed medical record review on 02/07/2023 revealed Patient #3, a 75-year-old female admitted for a Left Total Hip Arthroplasty on 01/20/2023. Review of the History and Physical dated 12/06/2022 by her Surgeon, Medical Doctor (MD) #1 revealed Patient #3 had Primary Osteoarthritis of the Left Hip. Patient #3's surgery on 01/20/2023 was without incident and she was admitted to the 2nd floor surgical unit at 1100. Review of the (named) ADC Report dated 01/21/2023 at 1143 revealed Registered Nurse (RN) #15 who removed Aspirin 81mg (milligrams) 1 TAB (tablet), Dexamethasone (steroidal medication) 10 mg/1 ml (milliter) Soln (solution), and at 1144 RN #2 removed Celecoxib (anti-inflammatory medication) 200 mg Cap (capsule), Hydromorphone/Dilaudid (narcotic medication for severe pain) 2mg/1ml 1ml sol-inj (solution-injectable) for Patient #3. Record review revealed RN #15 pulled 4 medications from the ADC for Patient #3. Review of the Medication Administration Record dated 01/21/2023 at 1228 revealed "...1144 (initials) Not Given...Edit Reason: Change admin (administration) documentation Not Given Reason: No IV Access..." Review of the (named) ADC Report dated -01/21/2023 at 1248 revealed Hydromorphone 2mg/1ml 1 ml Sol-Inj was wasted by RN #15, and witnessed waste was by RN #16. Review revealed Dilaudid IV pain medication pulled at 1144 by RN #15 for Patient #3, had not been administered due to no IV access, and was wasted by RN #15 at 1248. (1 hour and 4 min later). Review revealed Patient #3 was discharged on 01/22/2023 at 1648 home with family.

Telephone interview on 02/09/2023 at 1040 with RN #15 revealed "...when I came in, she was in pain...I pulled the medications, Decadron and Dilaudid. The IV didn't work, I left the room to ask (named) RN to come and try the IV... So, the Decadron, Dilaudid and meds were opened, because I had scanned them and told the patient what they were. I did leave them in the room on the sink. I left them, I had scanned them. Once she realized the IV wasn't working the patient wanted to wait to take all of her medications. It was 30 minutes or less I had to call the doctor to get new orders for pain, because the patient did not have IV access..." Interview revealed RN #15 scanned and opened 4 medications for Patient #3 at the bedside and left the medication unattended in the patient's room, while she left to call the physician. Interview revealed hospital policy was not followed.

Interview on 02/09/2023 at 1452 with Nurse Manager, RN #17 revealed "...the expectation was that medications should never be left unattended by the nurse..." Interview revealed the expectation was for RN #15 to have wasted or returned medications after Patient #3 had declined to take them. Interview revealed hospital policy was not followed.

Interview on 02/09/2023 at 1141 with Director of Medical-Surgical, RN #18 revealed "...we have an opportunity, we clearly need more training for medication safety and security..." Interview revealed the expectation was for medications never to be left unattended by the nurse. Interview revealed hospital policy was not followed.

NC00198013

Based on facility policy review, medical record review, and staff interviews, the hospital staff failed to ensure a patient received the scheduled medications by failing to document medication administration for 1 of 1 patients with home medications ordered reviewed. (Patient #2).

Findings include:

Review of Hospital policy titled Medication Administration with a review/revised date of 07/2020 revealed "PURPOSE: To accurately administer medications in accordance with all federal and state laws as well as the rules and regulations of the medical staff ... All medications brought in from home to be used must be sent to the Pharmacy for identification and bar coding. The medication is then returned to the nursing unit and placed in the patient's medication drawer ...All prn (taken as needed) medications should have the outcome of the administration documented within one hour of administration ...Medications given are charted for the hours given. Missed doses are documented with the reason for the omission (e.g. [such as], sleeping, off unit, etc.) ..."

Review of Hospital policy titled Medication Reconciliation with a review/revised date of 10/2020 revealed "PURPOSE: A. EMERGENCY DEPARTMENT A medication history (including medication name, dosage, route, and frequency) will be obtained from the patient/family/referring facility/patient's pharmacy. This information will be entered into the EMR (Electronic Medical Record) system - (Named system). If the patient is discharged from the Emergency Department the patient/family/referring facility will receive instructions regarding changes to the home medications and/or to continue the home medications as part of the discharge instructions. Upon discharge the patient will receive a copy of discharge instructions.

Closed medical record review on 02/07/2023 revealed Patient #2 was a 16-year-old male who presented to the Emergency Department (ED) on 07/29/2022 at 1509 on Nurse's Note with a chief complaint of "police report pt (patient) mother called for help after he assaulted his mother then grabbed a knife to harm himself ..." Record review revealed Patient #2 had a 7-day length of stay which included Involuntary Commitment (legally forced to present to the hospital for psychiatric evaluation and treatment). Record review of Physician Documentation obtained on 07/29/2022 at 1604 revealed " ...Medication Reconciliation Form: Guanfacine (medication to decrease excessive stimulation and treat Attention Deficit Hyperactivity Disorder [a chronic condition including difficulty to stay focused and high impulsiveness] 3 mg oral tablet extended release 24 hr. daily (in AM) continue on 07/31/2022, Aripiprazole ([Abilify] medication to treat psychotic response of Schizophrenia, Bipolar Disorder and irritability associated with Autism) 10 mg oral tablet every day at bedtime (in PM) continue 07/30/2022, Zofran 4mg oral tablet (one oral tablet every 6 hrs. prn [as needed] nausea/vomiting) continue every 6 hours as needed for nausea/vomiting. Record review of the Medication Reconciliation Form revealed Guanfacine 3mg oral tablet (start 07/31/2022 at 1000 with stop 08/19/2022 at 2201), Abilify 10mg oral tablet (start 07/30/2022 2100 with stop 08/19/2022 at 2101), and Zofran 4mg oral tablet (start 07/30/2022 at 1852 with stop 08/20/2022 at 1851 as needed every 6 hours, nausea/vomiting) were to continue entered by MD #2. Review of the Medication Administration Record revealed the order for Patient Own Med, Guanfacine ER 3mg once a day oral, scheduled at 1000 (start 07/31/2022 - stop 08/20/2022 at 1001) and Abilify 10mg at bedtime oral, scheduled at 2100 (start 07/30/2022 - stop 08/19/2022), Zofran 4mg every 6 hours as needed (start 07/30/2022 - stop 08/20/2022). Review revealed the Admission Medication Reconciliation Form was documented of medications to continue on 07/30/2022 at 1700 as faxed. Review of the Medication Administration Record revealed the Nursing staff failed to administer Patient #2 on 08/02/2022 Guanfacine 3 mg orally at 1000, Abilify 10 mg orally at 2100, and on 08/04/2022 Abilify 10 mg orally at 2100. Review of the Medication Administration Record revealed on 08/05/2022 Abillify 10 mg and Guanfacine 3mg orally was administered off schedule without documented reason for alteration in schedule as per physician order. Review of Physician Documentation on 08/06/2022 at 0305 revealed, "Patient was re-evaluated by tele psychiatry. They came up with a discharge plan for the patient. He no longer feels suicidal ...He is otherwise hemodynamically stable. Medically cleared for outpatient management ...It is felt that the patient is safe for discharge ..." Record review revealed Patient #2 was discharged in the company of his parent on 08/06/2023 at 0318 to home.

Interview with the Director of Nursing for the ED on 02/07/2023 at 1630 revealed it was the expectation of the nursing staff to have the Pharmacy Department identify home medication brought into the hospital that the physician deemed for continue patient usage. Interview revealed it was the expectation of nursing staff to confirm medication administration with date, time, site of administration and the RN initials of the staff person.

Interview with RN assigned to Patient #2 on 07/30/2022 dayshift (0700 through 1900) and 08/02/2022 dayshift (0700 through 1100) was unavailable.

Interview with RN assigned to Patient #2 on 08/02/2022 nightshift (1500 through 0300) was unavailable.

Interview with RN assigned to Patient #2 on 08/04/2022 nightshift (1900 through 0300) was unavailable.

Interview with RN assigned to Patient #2 on 08/05/2022 nightshift (1900 through 0700) was unavailable.

NC00192196