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Based on the certification survey completed on Sept 25, 2013, the facility was found not in compliance with Life Safety Code requirements at CFR ?485.623(d).

Refer to Life Safety Code deficiencies at regulations; K-0011, K0018, K0029, K0046, K0050, K0052, K0054, K0067, K0069, K0079, K0077, K0144 for additional information.

The cumulative effect of these systemic problems resulted in the Critical Access Hospital's inability to ensure safety from fire therefore they were unable to meet this condition.

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Based on interview and document review the critical access hospital (CAH) failed to ensure pharmacy policies were implemented related to the immediate notification of the physician upon discovery nor the implementation of follow-up interventions/actions to minimize further errors/incidents. In addition, the pharmacist did not consistently review medication errors nor implement interventions to minimize reoccurrence for 10 of 10 mediation errors reviewed. These practices have the potential to affect all CAH patients.

Findings include: Medication errors were not consistently reported to the physician immediately and then reviewed by the pharmacist and/or the director of patient services (DPS). Documentation was lacking to indicate that action/interventions had been implemented to prevent or reduce further incident of errors.

During interview with the registered pharmacist (RPh) director on 9/24/2013 at 11:00 a.m., it was stated that medication errors are sent to the DPS or pharmacy. She indicated the physician should be notified as soon as a medication error had been discovered. However, she also stated the nurse filling out the medication error form had the discretion on whether or not to notify the physician. The RPh director indicated she did not always get involved in implementing interventions/actions to prevent reoccurrence of medication errors, but that the errors were reviewed at the pharmacy meetings.

Upon review of the facility policy, the RPh verified the policy did not mention/note the immediate notification of the physician upon discovery of medication errors.

The Pharmacy and Therapeutics (P&T) committee (advisory group that serves as the organizational line of communication or liaison between the medical staff and the pharmacy department) meeting minutes from January 31, 2013 were reviewed. The meeting addressed the following: number of errors, type and severity of errors, but lacked evidence of analysis and subsequent intervention(s) to prevent and/or reduce reoccurrence. No further P&T meeting minutes were provided by the facility.

Medication error reports from 1/8/2013 -7/4/2013, were provided by the director of nursing (DON). Ten medication errors had occurred; however, there was no evidence the acting pharmacy director or any staff from the pharmacy or the director of nursing (DON) had reviewed these medication errors.

Review of the CAH policy, Medication Variance Reporting, dated as last reviewed/revised on 9/13, revealed the following:
Procedure 3.2: Any medication incident shall be reported upon discovery using the Medication Variance Reporting Form,
3.2.1.1: Follow-up with physician shall occur for variances that reached the patient,
3.2.3.1: Details the reasons the variance may have occurred and allows other comments regarding how the variance could have been prevented.
3.4 read: Director of Nursing, Pharmacy and the Pharmacy and Therapeutics Committee will review incidence if so determined.

The DON, interviewed on 9/24/13, at 1:30 p.m., stated the pharmacist was responsible for follow through on these reports and would bring them to the P& T meetings. She confirmed the P&T committee had not met since 1/31/2013 and therefore had not reviewed medication errors since. After a report is filled out, it was routed to the pharmacist and that she may receive the errors at the time of the P&T meeting and then they are discussed and reviewed.

The administrator, interviewed on 9/24/2013 at 2:30 p.m., stated the medication errors are reviewed at the P&T meetings. However, P&T meetings had not occurred since 1/31/2013. She also confirmed a system was not in place currently to follow up on the medication error reports.