HospitalInspections.org

Based on record review and interviews nursing failed to provide drugs and biologicals in accordance with the approved medical staff policies and procedures in that the patient provided antidepressant medication Viibryd for one of one patient (Patient #2) was not processed according to hospital policy.

Findings included:

The hospital's "Patient's Own (Home) Medications" policy (Policy#DD5.34), not dated, noted that "...once received in the unit, 2 nurses document the number or amount of patent's own (home) medication in the eMAR [electronic medication administration record] under comments."


Patient #2's Registration Form reflected Patient #2's hospital admission date of 06/27/13 at 14:03.

Admitting orders for Patient #2 were dated 06/27/13 at 16:09. A document labeled "Medications" dated 06/27/13 at 16:09 reflected an order for Viibryd 40mg (milligram) daily and "patient supplied medication."

The History and Physical documentation dated 06/27/13 at 17:44 noted Patient #2 was admitted for major depression.

Patient #2's Medical History Form dated 06/27/13 reflected the patient had been taking Viibryd 40mg for more than six months.

The Medication Administration Record dated 06/28/13 reflected Viibryd was a patient supplied medication and had been identified by pharmacy on 06/28/13.

Hospital Personnel #2 stated during an interview on 08/22/13 at 10:25 AM that Viibryd was not on the hospital's formulary and needed to be administered from patient own supply. Hospital Personnel #2 stated Patient #2's Viibryd medication was ordered on 06/27/13 at 16:20 to be administered daily at 9:00AM. Pharmacy identified the home brought medication as Viibryd on 06/28/13 at 11:15 AM. Patient #2 received her Viibryd medication on 06/28/13 at 11:50 AM as "a late dose."