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Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure that medications brought from home are inventoried upon admission in accordance with facility policy (A0398).

Cross reference:
482.23(b)(6) - Supervison of Contract Staff

Based on the review of four of ten medical records for Patient (P)1, P6, P7, and P10, staff interviews, and review of facility documents, it was determined the facility failed to ensure that medications brought from home are inventoried upon admission in accordance with facility policy.

Findings include:

Facility policy titled, "Patient's Own Medication Storage and Use During Hospitalization" effective 4/28/23 stated, "... Procedure: On Admission ... 1. Upon admission, the nurse will ask every hospitalized patient to present all personal medication in his/her possession ... 2e. Nursing will document in the EHR [Electronic Health Record] that a POM [Patient's Own Medication] will be stored in the pharmacy..."

On 4/23/25 a review of P1's medical record was conducted and revealed the following:

P1 arrived at the facility's ED on 11/9/24 at 2:02 PM with a chief complaint of abdominal pain. At 3:54 PM, the Provider discussed with P1 the plan to admit to which the patient agreed. At 4:51 PM, P1 was transferred to an inpatient bed on 2W [2West], a Medical-surgical unit. At 7:30 PM, the nursing assessment lacked documentation that belongings including medications brought from home were inventoried. On 11/10/24 at 10:33 AM, P1 was examined bedside by the admitting physician. The Significant Event Note from 11/10/24 at 9:13 PM stated, " ... Code blue called at 8:35 PM for patient having unresponsiveness ...from the bathroom, had a bottle of pills in a prescription bottle labeled as Cipro[Ciprofloxacin] but containing 4 mg [milligrams] Dilaudid tablets. Patient was intubated by RT [Respiratory Therapist] successfully, initial rhythm PEA [Pulseless Electrical Activity] throughout code. Due to lack of perfusing rhythm, pronounced as deceased at 9pm. Pupils fixed and dilated, absent heart and lung sounds. ... 10:06pm notified by charge nurse that white powdery substance was also found around the sink in patient's bathroom with scattered pills. ..." A review of the security narrative stated, " ...Security followed up with Medical Records for patient belongings. Medical Records advised there are no 'Inventory Belongings Form' ... no visitors recorded visiting [P1] ..."

During the review of P1's medical record, the section, " ... Medication brought by patient ... yes no ..." failed to indicate that the patient's belongings were assessed and inventoried to include medications brought from home, upon admission.

At 10:46 AM, an interview was conducted with S11 (RN) on the 2W unit who was asked about the process for belongings of patients that arrive from the ED. S11 stated, the floor does their own inventory of belongings and documents in the electronic medical record (EMR) once the patient reaches the unit. S11 was asked to explain the process for home medication brought to the unit. S11 explained, all medication is inventoried and sent to the pharmacy in a sealed bag for verification. The pharmacy profiles the medication and if it is not a formulary medication, it is dispensed by the pharmacy when the patient needs it. If it is a formulary medication, the patient is informed that the same medication will be given to them while they are in the facility. The patient's medication remains in the pharmacy and the patient receives their medication back when they are discharged. If the patient has controlled medications that are non-formulary, they are dispensed from the pharmacy one pill at a time. S11 added, the status of any home medication is documented in the patient's chart as 'sent to pharmacy' or 'sent home with family'.

At 10:54 AM, an interview was conducted with S13 (RN) on 2-West. S13 was asked about the process for home medication and stated, medication brought with the patient is sent to the pharmacy with a medication documentation sheet. One copy goes to the pharmacy and the other copy goes inside the patient belongings bag. S13 stated the medical record is then updated to reflect that the patient brought their own medication, then it will be sent to the pharmacy. S13 then demonstrated how to document if a patient brings medications from home in the EMR. Under the patient belongings section, medications brought from home is a yes or no question, which should be completed upon admission when inventorying the patient's belongings.



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Additional medical records reviewed, revealed the following:

P6 presented to the ED on 4/21/25 at 3:51 PM with a complaint of Cough, and Shortness of Breath. P6 was admitted on 4/21/25 at 6:59 PM to 2-West Medical/Surgical unit. The section, " ... Medication brought by patient ...yes no ..." was not marked. P6's medical record lacked documentation that medications brought from home was assessed upon admission.

P7 presented to the ED on 4/19/25 at 9:51 AM with a complaint related to reproductive health. P7 was admitted on 4/19/25 at 4:32 PM to 2-West Medical/Surgical unit. The section, " ... Medication brought by patient ...yes no ..." was not marked. P7's medical record lacked documentation that medications brought from home was assessed upon admission.

P10 presented to the ED on 8/29/24 at 5:38 PM with a complaint of Altered Mental Status. P10 was admitted on 8/30/24 at 4:50 PM to 2-West Medical/Surgical unit. The section, " ... Medication brought by patient ...yes no ..." was not marked. P10's medical record lacked documentation that medications brought from home was assessed upon admission.

On 4/23/25 these above findings were reviewed with Staff (S)1 (Nurse Manager 2 West Medical/Surgical unit and Covering Director of Nursing), S2 (Director of Nursing ED), S3 (Risk Manager), S4 (Chief Medical Officer), S5 (Accreditation Manager), S6 (Quality and Patient Safety), and S7 (Executive Director Risk Management. Upon interview, S1 confirmed medications brought in by a patient is part of the admission assessment during the inventory of belongings. Every patient should be asked if they brought any medications. S1 also confirmed every patient should have documented "yes or no" for medications brought by patient in their medical record. If a patient brings their own medications, they should be inventoried then sent to the pharmacy or sent home.

At 1:12 PM, S1 was asked if education related to belongings and medication brought from home was provided to 2-West staff after the incident involving P1 occurred, S1 stated he/she has discussions during huddle with staff. S1 then confirmed there was no education provided to staff related to belongings and medications brought from home since the incident occurred with P1.