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CRESTWYN BEHAVIORAL HEALTH
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on policy review, medical record review, and interview, the facility failed to ensure all patients received care in a safe setting related to the security of their personal medications brought from home for 1 of 3 (Patient #1) sampled patients.
The findings included:
1. Review of the facility "MEDICATIONS BROUGHT IN WITH PATIENTS" policy revealed, "...All medications are given back to the patient's family to be taken home if possible...If the patient's family cannot be notified, then all medications are placed in a tamper resistant/inventory bag. A list of the medications will be written on the approved inventory bag by the Admissions staff or nurse receiving the medications and will include the patient's name and list of medications. Controlled substances that cannot be returned to family must be counted with the quantity noted on the inventory bag. The patient/caregiver and the staff member receiving medications will sign the Medication Reconciliation form as proof that inventoried medications were received and secured...Copies of the Medication Reconciliation form are kept in the patient's medical record...If a patient has controlled substances being returned at discharge, the quantity being returned to the patient must be noted by the nurse (and witness if available) on the Medication Reconciliation form. The patient or caregiver must also verify that the count is correct..."
2. Medical record review revealed Patient #1 was admitted to the facility on 2/22/19 with diagnoses which included Depression and Anxiety. There was no Medication Reconciliation Form documenting the medications Patient #1 brought from home, in the medical record.
3. During a telephone interview on 4/3/19 at 11:00 AM, Patient #1 revealed she was discharged from the facility on 2/27/19. At that time the facility returned her medications to her and she was missing 4-10 mg (milligram) tablets and a bottle of Doxepin 50 mg capsules.
During a telephone interview on 5/1/19 at 2:23 PM, the Risk Manager verified the facility did not follow their policy for Patient #1.