HospitalInspections.org

Based on review of hospital policy, Registered Nurse job description, observation, staff and family interviews and medical record reviews, the hospital's nursing staff failed to supervise and evaluate nursing care by allowing family members to administer home medications without a physician's order and pharmacy oversight for 1 of 1 patients self-administering medications (#2).

The findings include:

Review of the hospital's policy, "Administration of Drugs: Patient's Personal Drugs", revised 01/2010, revealed, "POLICY A patient's personal drugs shall only be administered to the patient upon the order of the patient's physician. ... PROCEDURE Unless administration of a patient's personal drugs is authorized by the responsible prescribing practitioner, these drugs shall be sent home with the family or others. If the drugs must be maintained in the facility, they shall be packaged, sealed, labeled with the patient's name, and maintained in locked storage. The medications should be inventoried and the patient given a receipt with a copy of the receipt placed in the patient's medical record. ...The pharmacy should affix a supplemental label to the container to verify that a physician has authorized the administration of the drug contained therein. ...Unless directed otherwise by the responsible practitioner, personal drugs to be administered shall be stored with other drugs supplied by the facility. ...".

Review of the hospital's job description for a Medical-Surgical Registered Nurse revealed, "...General Job Duties"...3. Notes and carries out physician's orders in a timely manner. ...13. Dispenses medication per law, regulation, licensure and hospital policy. 14. Controls access to medications per hospital policy. ...".

Open medical record review for Patient #2 revealed a 58 year-old male admitted 09/05/2011 with intractable abdominal pain. Record review revealed Patient #2's medical history included traumatic brain injury with quadriplegia. Record review revealed a physician's order dated 09/15/2011 at 1251, "Continue Home Medications" followed by the following medications: Keppra (anti-seizure medication) 1000 mg (milligrams) via PEG (percutaneous endoscopic gastrostomy - feeding tube), Aspirin 81 mg via PEG daily, Vesicare (over-active bladder medication) 5 mg via PEG daily, Folic Acid 1 mg via PEG daily, Lamotrigine (anti-seizure medication) 100 mg via PEG daily, Ativan (anti-anxiety medication) 1 mg via PEG at bedtime, Calcium with Vitamin D 600 mg via PEG daily and Lactulose (laxative) 30 ml (milliliters) twice daily via PEG.

Observation on 09/08/2011 at 1100 of a Staff Registered Nurse (RN #1) administering medications to Patient #2 revealed RN #1 administered Ferrous Sulfate 300 mg via PEG and Lactose 30 ml via PEG. Further observation revealed the following non-secured medications in the patient's room on the counter by the sink: Keppra, Aspirin, Vesicare, Folic Acid, Lamotrigine and Calcium with Vitamin D. Observation of the medications failed to reveal a label noting the medications had been reviewed/approved by the hospital's pharmacy.

Interview on 09/08/2011 at 1100 with RN #1 revealed Patient #2's family members administer Keppra, Aspirin, Vesicare, Folic Acid, Lamotrigine and Calcium with Vitamin D via the patient's PEG. Interview further revealed, "I thought the order to continue home medications meant it was ok for the family to administer the meds". Interview confirmed there was not a physician's order for the patient's family members to administer medications. Interview confirmed the medications brought in by the patient's family from home had not been reviewed/approved by the hospital pharmacy.

Interview on 09/08/2011 at 1115 with Patient #2's sister revealed, "we always administer his (Patient #2) medicine. Nobody ever questioned us". Interview further revealed the hospital pharmacy staff had not reviewed the medications brought from home.

Interview on 09/08/2011 at 1540 with the hospital's pharmacist revealed that medications brought in from home should not be kept in the patient's room. Interview revealed the nurse should have notified the pharmacy, the pharmacist would have reviewed the medication, affixed a label to the medication and stored the medication in the unit's locked medication room in a red bin with the patient's name affixed to it. Interview further revealed, "family members should not be allowed to administer medications unless there is a physician's order to do so. Only nurses should administer drugs".

Based on policy review, log review, medical record review and staff interview, the hospital's medical record staff failed to ensure a complete medical record was available upon request for 1 of 10 medical records requested (#1).

The findings include:

Review of "Recovery of Missing, Destroyed or Damaged Paper Records" policy effective 2003 revealed "State, Federal and accrediting agencies laws, rules, regulations and standards require that a medical record be created and maintained for each patient seen or treated in a health care environment."

Review on 09/07/2011 of an "Inpatient Discharge Register" revealed Patient #1 was admitted 06/09/2011 and discharged 06/10/2011. Review of the log revealed the patient was a 30 year-old female admitted to the hospital's Intensive Care Unit (ICU). Review of the hospital's Incident Log revealed Patient #1 left the ICU against medical advice (AMA) on 06/10/2011.

A request was made for Patient #1's medical record on 09/07/2011 at 1300. A medical record for Patient #1 was received with an admission date of 06/10/2011 and discharge date of 06/17/2011. Review of the medical record revealed Patient #1 was readmitted on 06/10/2011 after leaving AMA on 06/10/2011.

Interview on 09/07/2011 at 1530 with an administrative staff member revealed the medical record for Patient #1 for the 06/09/2011 through 06/10/2011 admission could not be found and the Health Information Management (HIM) staff would continue looking for the misplaced record.

Interview on 09/08/2011 at 1025 with administrative staff revealed the medical record for Patient #1 for the 06/09/2011 through 06/10/2011 admission was not found. The staff member presented parts of the medical record that had been printed from electronic records that included a History and Physical, Discharge Summary, lab and radiology reports and emergency department records.

Interview on 09/08/2011 at 1245 with the HIM Director revealed the staff member was unable to locate non-electronic parts of Patient #1's medical record for the admission date of 06/09/2011. The staff member confirmed that the patient was admitted on 06/09/2011 through the emergency department to the ICU. Interview revealed the electronic components of the record were available, but the record was not complete. Interview confirmed missing components of the medical record included physician's orders, nursing notes, physician progress notes, medication administration records, vital sign monitoring, against medical advice form and consent forms. The staff member stated "We can't find it."