HospitalInspections.org

Based on a review of facility documents, a closed medical record (MR), and staff interviews (EMP), it was determined that Indiana Regional Medical Center failed to follow adopted policies related to the disposal of controlled pain patches for one of one medical records reviewed (MR1), and failed to ensure the accurate recording of a drug administered to a patient in one of one medical records reviewed. (MR1)

Findings include:

A review of the Pharmacy Policy entitled "Controlled Substances Waste/Duragesic Patches," reviewed April 2015, which stated, "Policy: Duragesic patches are to be folded and placed into the sharps container and two signatures will be required to verify that this procedure has been followed ... ."

A review of a document notated as Key Points Sheet (KPS) with Title "Controlled Medication Waste," revealed, "Objective: Provide guidelines for the waste of controlled medications ... Key Step 2: Controlled Pain Patches (ie. Duragesic Patch) -Waste of controlled pain patch medication must be witnessed by a second licensed person.-Apply gloves and remove patch from patient.-Fold the patch in half, medications sides together.-Dispose of patch in the sharps container.-Note waste in Omnicell. Key Step 3: How to Document Waste of Controlled Pain Patch When Patient Arrives from Outside Facility (with a Patch in Place) -Document waste in the nurses' notes."

A review of Nursing Policy entitled "Medication Administration," dated July 2014, revealed, "... Medications and treatments are administered only upon the written and signed orders of practitioners acting within the scope of their licenses and authorization according to the Medical Staff By-Laws, Rules and Regulations ... Guidelines for Administering Medications ... Controlled Medications Practice Guidelines: ... On designated units, automatic dispensing units are also utilized to store and dispense controlled medication. (See Automated Dispensing Unit Policy) ... If a narcotic patch is removed for any reason (i.e. new patch applied, patch is discontinued, patch removed for procedure) proper narcotic waste will occur, in the presence of a witness and co-signature ... ."

A review of the nursing policy entitled "Administration of IV Medications," dated August 2014, revealed, "...Guidelines for Administration of Intravenous Medications ... Record on eMAR ... ."

A review of the facility's policy entitled "Medication Administration," dated July 14, 2015, revealed, "... Medications and treatments are administered only upon the written and signed orders of practitioners acting within the scope of their licenses and authorization according to the Medical Staff By-Laws, Rules and Regulations ... Bedside Medication Verification ... Document administration date/time & "Given" and site administered if applicable ... ."

1. A review of MR1 revealed that the patient was admitted to the facility on March 26, 2015. Documentation within the patient's medical record revealed that prior to admission, the patient had a Fentanyl patch on, which was placed by an extended care facility on March 25, 2015.

Review of additional documentation provided by the facility, it was noted that the patient was ordered a Fentanyl patch every three days. Continued review of the Medication Administration Records within MR1, noted that a Fentanyl patch was placed on March 28, 2015.
During review of nursing documentation, within MR1, it was noted that there was no documentation that the Fentanyl patch the patient had on admission, was removed and wasted, per facility policy, when the March 28, 2015, patch was administered.

2. An interview with EMP2 on September 24, 2015, revealed, "Fentanyl patch is applied every three days. You pull a new one from the Omnicell and remove the old. There should be a second RN to verify the waste. The patient came in on March 26th and the patches were found on April 6th, EMP15 found the patches. They were ordered on admission. A new patch was placed on March 28, 2015, to the right deltoid. Then the patient had one placed on March 31st, April 3rd, and April 6th. On April 3rd, there was no documentation of removing the old patch. On April 6th, they found the three patches. There were documentation issues found with the removal of patches. ... ."

3. MR1 Nursing documentation April 6, 2015, 0853: "... When assessing patient found 3 total Fentanyl patches 1 on left delt one on rt delt 1 on l chest wall the one on left chest wall was dated 4/3 the other 2 had no dates. All removed and new one put on. Disposed of 3 meds and EMP18 witnessed me disposing of them ... ."

4. On October 21,2015, at approximately 1:00 PM, EMP1 confirmed "that no, we were not able to find documentation of the location of the patch the patient should have had on from the nursing home at the time of admission. ... ."



5. An interview with EMP15 on September 25, 2015, at 10:00AM, revealed, "When I was in the room doing my assessment of the patient, I rolled the patient over and noticed a patch on the back of the right deltoid area. There was one on the right chest wall with a date, and then one on the left deltoid. All of them said Fentanyl. The clear one on the right deltoid was the same shape as the one on the chest. The other deltoid was a rounded off square flesh toned patch. The one on the chest had the date. Most nurses would remove the old patch and then initial the new one. For disposal there is another nurse that goes with us and disposal is in biohazard container. The physician and family were notified."


6. A review of MR1 revealed a physician's verbal order dated March 26, 2015, 1700 for Morphine 2 mg IV q 6 PRN. A review of medication administration records revealed documentation that the patient received Morphine Sulfate 2 mg IV on March 26, 2015, at 1600.

7. Additional Omnicell Documentation (Transactions by Patient), relative to the patient MR1 was reviewed. It was noted that the document did not reveal any Morphine Sulfate pulled for the patient on March 26, 2015, at 1600.

Subsequently, another Omnicell document (Transactions by User) was provided to surveyors. It was noted that on March 26, 2015, at 4:00 PM, EMP14 pulled Norco 5/325 mg Tab for patient MR1 on March 26, 2015, 4:58 PM, pulled Morphine Sulfate 2 mg 1 ml Carp, for another patient PT1, and on March 26, 2015, 7:58 PM, pulled Morphine Sulfate 2 mg 1 ml Carp for patient MR1.

Subsequent documentation provided by EMP13 revealed, regarding the other patient, PT1, "... Administration History Detail ... Scheduled 03/26 1700 Administered 03/26 1720 Given: No ... Med pulled from Omnicell under wrong patient account, this pt did not receive Morphine ... ."

8. An interview with EMP2 on September 24, 2015, at approximately 2:00 PM, revealed, "... It was pointed out about the the order, EMP14 wrote the wrong time ... ."

9. A telephone interview with EMP14 on October 9, 2015, at approximately 1:30PM, revealed, "... I got the patient from the previous nurse. I assessed the patient. The patient was in a whole bunch of pain. I called EMP17 and got a verbal order ... The patient had a nine of ten on the pain scale, which made it an emergent need, I gave the Morphine ... then I made a transcription error ... ."