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Based on interview, record review, and observation, the hospital failed to ensure that one of one patient (Patient # 1) received prescribed medication at the scheduled time as written per physician orders.

Findings Included

1.) Physician orders were written for Patient #1's medication to be administered at 1930 and 2100 on 07/15/15 and 07/16/15. The Medication Administration Record (MAR) noted Patient #1 did not receive Depakote 1250mg, Thorazine 25mg and Cogentin 1mg as ordered.

2.) During an interview with Personnel #6 at 9:30 AM on 06/03/16 it was reported, "There are occasional problems with the Pyxis Medication Dispensing System having to be rebooted, and it will not unlock and dispense medication. It is a very rare thing. In the 4 years I have worked here it has happened 3 times."

3.) During the tour of the hospital at 9:30 AM on 6/03/16, Personnel #6 walked the surveyor through the process of the automated medication dispensing system and how medication is dispensed. During this time Personnel #6 indicated when the system went down there was no medication that was available to the patients.

The hospital Pharmacy Services Policy/Procedures dated 10/2012 included, "Provide a process for continuation of pharmaceutical care to all patients in the event of a network interface, power, or complete cabinet failure."