HospitalInspections.org

Based on interview, policy review and medical record review, the facility failed to ensure drugs were prepared and administered in accordance with the orders of the practitioner or practitioners responsible for the patient's care for one of 10 patients reviewed (Patient #1). This could affect all patients receiving services from the facility. The facility census was 67.

Findings include:

The medical record review for Patient #1 was completed on 07/08/21. The patient was admitted to the facility on 06/01/21 at 1:20 AM. The patient initially presented to another facility's emergency department with a complaint of suicide ideation.

A review of a social worker note from that facility dated 05/31/21 at 10:50 PM stated he had a recent medication change that had affected him negatively. The note stated he had thoughts of suicide, not feeling safe within himself to not hurt someone, and feeling dangerous to others as he could not control his thoughts and anger.

A review of the transferring facility's documentation revealed an application for emergency admission due to the patient having some suicide and homicidal behaviors and having fears of hurting himself or others coinciding with taking a new medication.
The medical record review revealed a physician order dated 06/01/21 at 11:00 AM that stated to stop all the medications he was taking at home, except Latuda (used treat certain mental/mood disorders such as schizophrenia, depression associated with bipolar disorder), which was to continue once a day with food.

A review of the facility's medication administration record revealed the patient had not received the medication on either 06/01/21 or 06/02/21 and revealed a physician order dated 06/03/21 at 10:04 AM to stop the medication. The medical record review did not reveal any clinical outcome from the medication getting missed.

On 07/07/21 at 1:30 PM in an interview, Staff A explained Latuda was not a formulary drug. She explained when the physician ordered non-formulary medications to continue to be taken while the person was an in-patient, the family will be asked to bring the medication in.

The medical record review did not reveal a physician order to hold the medication until it was brought in, and did not reveal where the nursing staff and medical staff discussed that the patient had not received the drug for two days.

A review of the facility's Management of Medication Errors policy, number PI.4, was completed on 07/08/21. The review revealed an error of omission is a medication error that has reached the patient. The review revealed, "Employees are expected to report medication errors and potential medication errors via the incident report form."

On 07/07/21 at 1:30 PM in an interview, Staff B confirmed the non-administration of Latuda was technically a medication error.

On 07/08/21 at 1:00 PM in an interview, Staff A confirmed an incident report regarding the missed administration of Latuda was not created.

Further review of the facility's Management of Medication Errors policy revealed "Medication errors will be trended by drug, location, severity, etc., by the Director of Pharmacy and Director of Nursing."

On 07/08/21 at 1:00 PM in an interview, Staff A said the facility had not been tracking and trending how often non-formulary medications were being missed between the time the order was written and the time the family brought the medications to the facility.

This deficiency substantiated Substantial Allegation OH00122976.