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Based on interview, observation and document review, the hospital failed to complete and update nursing care plans based on current patient needs. Failure to complete nursing care plans may prolong a patient's hospitalization.

Findings include:

The medical record is a hybrid between paper and electronic documentation. On review of eleven electronic medical records, three patient assessments (Patient 2, 4 & 8) identified special needs related to fall precautions and skin precautions. These identified care concerns requiring interventions were not found on the Patient Plan of Care for Patient 2, 4, or 8.

Based on interview, observation and review of facility policy and procedures, the hospital failed to follow their policy on Medication Systems regarding medication inspection prior to administration. Failure to follow the policy may place patients at risk of receiving expired medications.

Finding include:
The hospital policy states in their Medication System policy (F.1.c) that prior to administration of medications, the nurse will "examine medication dispensed for expiration date and any unusual color, odor or consistency". The investigators observed three intravenous medications (Cefazolin, Vancomycin x 2) on three separate nursing units and found no clearly labeled expiration date. Three registered nurses (RN #5, 7 and 8) were interviewed and no expiration date on the medications could be identified by the three nurses.

Based on interview, observation and document review, the facility did not have records documenting the total process of distribution of scheduled drugs from the receipt of drugs into pharmacy to the administration of medications to the patient. Failure to maintain accurate records may result in loss or theft of scheduled medications.

The respondent facility has a policy and corresponding procedure (including documentation) for monitoring the movement of scheduled drugs from receipt into the pharmacy to placement for distribution to patients in the Pyxis machine (automated medication dispensing system). The facility did not have a proactive process to monitor any discrepancies between records of medications stocked by pharmacy in the Pyxis machine and medications taken out of the Pyxis machine for administration to patients. The facility had a reactive process to monitor discrepancies between medications taken out of the Pyxis machine, but not given to a patient.

The investigators were told by the Director of Quality and the Director of Pharmacy that the policy regarding discrepancy monitoring was revised within the last month (May 2014) to include a proactive approach to monitoring that medications intended for patients are actually administered. Staff training was in process at time of survey with an immediate implementation date. Monitoring of the process will be the responsibility of both Nursing and Pharmacy leadership and forwarded through the quality review system.

Based on interview, observation and review of facility policy and procedures, the hospital failed to follow their policy on Medication Systems regarding medication inspection prior to administration. Failure to follow the policy may place patients at risk of receiving expired medications.

Finding include:
The hospital policy states in their Medication System policy (F.1.c) that prior to administration of medications, the nurse will "examine medication dispensed for expiration date and any unusual color, odor or consistency". The investigators observed three intravenous medications (Cefazolin, Vancomycin x 2) on three separate nursing units and found no clearly labeled expiration date. Three registered nurses (RN #5, 7 and 8) were interviewed and no expiration date on the medications could be identified by the three nurses.

Based on interview and document review, the suspected abuse and loss of medications was not immediately reported to the individual responsible for the pharmaceutical services. Failure to do so does not provide for a timely and thorough investigation of scheduled drug loss/abuse.

Prior to the internal investigation related to this complaint, the investigation of a potential substance abuse/diversion issue by a nurse was controlled by nursing leadership. Pharmacy was not immediately notified and did not participate in the investigation. The process was revised May 2104 and now includes immediate notification to pharmacy in the event of a potential diversion. The respondent facility created a Drug Diversion Response Team to address issues with a systematic approach starting June 2014 to include participation by both pharmacy and nursing.

The plan of correction includes policy revision, mandatory staff education and concurrent monitoring for all substance abuse/loss/diversion issues. This information will be reviewed by the Pharmacy and Therapeutics Committee, Quality Council, Executive Leadership and the Board of Governors outlined the the hospital Quality Improvement Plan.