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Based on review of policies, review of medical records, and interviews with staff, the facility staff failed to identify and investigate a grievance related to patient valuables in 1 of 2 sampled patients (#21).

The findings include:

Review of a policy titled "Patient and Family Grievances" with a revision date of 04/19, revealed "A patient grievance is defined as a formal or informal written or verbal complaint that is made to the hospital by a patient, or patient's representative, regarding the patient's care when the complaint is not resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, requires further actions for resolution...issues related to the hospital's compliance with the CMS Hospital Conditions of Participation...."

Review of a closed medical record of Patient #21 revealed a 51 year old male admitted on 09/04/2019 for Major Depressive Disorder. Review of a Patient Valuables Envelope of contents for Patient #21 dated 09/04/2019 revealed "$25 dollars, NCDL (North Carolina Driver's License), 2 Bank Cards, Shoe strings." Review of Patient #21's Patient Valuables Envelope dated 09/11/2019 revealed "Silver tone ring w/rose prints--(left behind by patient)." Patient was discharged on 09/11/2019

Interview on 09/19/2019 at 1700 with RN #8 revealed Patient #21 reported to her that his ring was missing a few days ago. Interview revealed Patient #21 reported he removed his ring while showering. The ring was missing when he ended his shower and he was unable to locate it. Interview revealed the assigned MHT #5 discovered the ring in another patient's pocket (Patient #20) during preparation for discharge on 09/11/2019. Review revealed Patient #20's discharge was cancelled. Interview revealed no incident report or grievance report was completed. Interview revealed the nurse was unsure why the grievance was not completed.

Interview on 09/19/2019 at 1610 with MHT #5 revealed he recognized the ring as belonging to Patient #21 from an earlier complaint when Patient #20's discharge had been cancelled. MHT #5 revealed Patient #20 had been placing personal items into a valuables bag for discharge when he noticed Pattient #21's ring. Interview revealed MHT #5 was told the ring had been placed in a ziplock bag by the charge nurse. Interview revealed MHT #5 heard the ring was locked in the safe.

Interview on 09/19/2019 at 1715 with CEO revealed the ring was found in the facility's safe during this survey and the ring will be returned to the owner (Patient #21).

Interview on 09/19/2019 at 1715 with the CEO revealed a grievance should have been completed.

Based on review of policy, review of medical records, and interviews with staff, the nursing staff failed to ensure a patient's safety by failing to complete medication reconcilation at admission for 1 of 6 sampled patients (Patient #2).

The findings include:

Review of a facility policy titled "Medication Reconcilation" with a revision date of 04/2019, revealed "Purpose: To provide a safe and effective process for obtaining, documenting, and communicating medications across a patient's continuum of care. Policy Statement: Medication Reconcilation is a formal process of obtaining a complete and accurate list of each patient's current home medications and then comparing the prescriber's admission, daily, transfer, and discharge orders to that list. Discrepancies or safety issues are identified by the prescriber and if appropriate, changes made to the orders.....PROCEDURE: Admission Reconcilation: 1. At the time of the admission, the admission nurse/clinician is to gather Medication History from the patient or other sources and enter the information into the (computer system)....6. The nurse will review the medication history with the admitting MD and enter the physician's orders into the (computer system). If physician orders a change in dosing or frequency, the nurse is to indicate that in the (computer system)....The nurse is to utilize READBACK procedure for the above process. 7. The nurse's entry into (computer system) indicates that the nurse has reviewed the medication history with the patient and the MD. 8. No new medications can be started without the medication reconcilation taking place with the MD....9. The unit nurse will then review the orders in the (computer system). A second nurse will review and sign, date and time the order. 10. The Admission Orders are sent to the pharmacy through the (computer system)."

Review of closed medical record of Patient #2 revealed a 57 year old male admitted on 08/12/2019 under voluntary status for ETOH (alcohol) abuse. Past medical history is significant for Pulmonary Embolism with a history of taking anticoagulant, Eliquis (Apixaban-- treats and prevents blood clots). Review of a medication reconcilation form dated 08/12/2019 revealed medication was listed: "Apixaban 5 mg tab po BID (milligrams tablet by mouth twice daily)." Review of Medicine Consult Note dated 08/14/2019 at 1020 revealed "...Pt (Patient) is on Eliquis 5 BID. Reordered. Unsure why it was held on admission...." Review of Medication Administration Record revealed "Apixiban (Eliquis) 5 mg oral twice a day for PE" was administered on 08/14/2019 at 2134 and 08/15/2019 at 0638. Review revealed Eliquis was not administered on 08/12/2019 or 08/13/2019.

Interview on 09/20/2019 at 1015 with MD #2 revealed medications are reviewed with the admission staff. Interview revealed typically the onsite physician sees the patient and reviews medications again.

Interview on 09/17/2019 at 1537 with MD #3, reviewing chart of Patient #2, revealed notes were made that patient #2 had history of pulmonary embolism. Interview revealed medications were reconciled by the admitting physician. Interview revealed Eliquis should have been ordered on admission.

Interview on 09/18/2019 at 1500 with the admission nurse, RN #7 revealed, reviewing the process, during admissions the medications are reviewed with the patient and verified with the physician. Interview revealed the physician is asked to order or discontinue medications. Interview revealed the nurse has to send the list to the pharmacy for medications to be dispensed and administered to the patient. Interview revealed there was no known reason of failing to complete the admission medication reconcilation. Interview revealed there is not a second nurse to double check the admission paperwork to verify its accuracy.

Interview on 09/18/2019 at 1335 with the DPI (Director of Performance Improvement) revealed pharmacy never received the home medications orders for this patient. Interview revealed the root cause was admission staff did not 'click' the green button to send the list to the pharmacist to verify.

Interview on 09/19/2019 at 0908 with a pharmacist, PharmD #1 revealed the admissions nurse failed to send Patient #2's medication list of ordered medications to the pharmacy and delayed the start of the Eliquis. Interview confirmed the medication was given on 08/14/2019 at 2134, two days after admission.

Based on review of policy, review of medical records, review of internal documents, and interviews with physician and clinical staff, facility staff failed to ensure continued administration of a chronic medication by failing to notify the physician the medication had been provided to the facility for 1 of 1 sampled patients (Patient #1).

Findings included:

Review of the policy "Medications Brought Into The Hospital by Patients" latest review date 01/2019 revealed "POLICY: It is the policy of (Named Facility) that the patient's own medications may be utilized if there is a physician's order stating that the patient may take his/her own medications and if the medications have been appropriately identified. PROCEDURE: ...3 ...If the patient requires medications that are not part of the hospital formulary, the family may be requested by the physician to bring those to the facility for use ...4. Home medications will be identified by the pharmacist and/or physician using recognized identification sources. After the medication has been identified, the medication are sent (sic) to the pharmacy for proper relabeling ...5 ...d. If the patient has brought in a high cost non-formulary medication ...the medication must be identified by the pharmacist or physician ..."

Review of the medical record revealed Patient #1 was a 57 year old female admitted to the facility under involuntary commitment determination on 06/20/2019. Review of the medical record revealed Patient #1's history included schizoaffective disorder bipolar type and she had recently experienced increased auditory hallucinations and assaulted a peer at the group home where she resided. Review of her prehospitalization medications revealed her treatment for schizoaffective disorder included asenapine (aka Saphris, an atypical antipsychotic medication) 5 milligrams (mg) orally in the morning and 10 mg orally at bedtime, and paliperidone (aka Invega, a long acting atypical antipsychotic medication with complex initiation and discontinuation guidelines) 234 mg intramuscularly every thirty days. Review of the record revealed no due date for the medication was recorded in the record and paliperidone was discontinued on the admission medication orders. Review of a "Psychiatric Progress Note" by a psychiatrist, MD #8, dated 06/22/2019 at 1100 revealed Saphris was increased to 10 mg orally twice a day. Review of a "Psychiatric Progress Note" dated 06/27/2019 at 0920 by MD #8 revealed the increased Saphris dose had helped alleviate Patient #1's symptoms, and "augmentation of Saphris with Risperidal (antipsychotic medication) or Prolixin (antipsychotic medication)" was being considered. Review of an "Informed Consent for Psychotropic Medications" dated 07/01/2019 at 1000, no dosing or route indicated, revealed use of Invega was agreed to, and the form had been signed by Patient #1 and MD #8. Review revealed Invega 3 mg orally twice a day (short acting form) had been ordered and started on 07/01/2019 at 0847. Review of Patient #1's discharge medication orders revealed electronically transmitted prescriptions by MD #8 on 07/05/2019 at 0721 for Saphris 10 mg orally twice a day, Invega 3 mg orally twice a day, and Invega 234 mg intramuscular every 30 days. Review of a "Multiple Antipsychotics Justification" transmission to Patient #1's pharmacy revealed the plan was to taper to monotherapy in the outpatient setting. Review revealed Patient #1 was discharged to her previous residential home with ACT team (community-based consultant health professionals who provide focused assistance in directing the care of specific individuals with severe, persistent mental illness) follow up on 07/07/2019 at 1440.

Review of the hospital formulary (a list of medications routinely prescribed and available at a medical facility) revealed the oral, short acting form of Invega was on the hospital's formulary, and the intramuscular long acting form of Invega was not on the hospital's formulary.

Review of an internal document revealed "1 Invega Injection" had been "dropped off" at the facility by a (Named) ACT team member on 06/25/2019 at 1119 and acknowledged by a pharmacist, PharmD #2, at 1121. Review of documentation also revealed the injection had been picked up by an ACT team member on 07/12/2019 at 1535.

Request to interview PharmD #2 revealed she was not available.

Interview with PharmD #1 on 09/18/2019 at 1410 revealed Patient #1's inpatient stay had occurred prior to his hiring on 07/21/2019 and the previous pharmacist, PharmD #2 was no longer at the facility. Interview revealed PharmD #1 was not familiar with Patient #1's medications.

Interview with the Director of Clinical Services (DCS) on 09/18/2018 at 1030 revealed he had been "pulled in for service recovery" after Patient #1 had been discharged. During interview DCS stated "the therapist, CM #7, had received notification the medication was there and should have communicated with the doctor and the team. She did not do that well." Interview revealed he had discussed the communication failure with the Director of Nursing (DON) during review of administration of medications, and nursing staff had been re-educated about their role related to outpatient medication brought to the facility. Interview revealed a new policy pertaining to medications received from outside sources had been developed in July after the incident but was currently awaiting formal approval by the facility's board.

Interview with the Director of Nursing (DON) on 09/18/2019 at 1115 revealed she had been involved initially as part of a "recovery." Interview revealed the ACT team had notified the facility Patient #1 had not received the monthly injection of Invega during her hospitalization after Patient #1's discharge. Interview revealed the DON did not recall when the medication had been due, but she "went in to see what had happened (and) the order was never put in for the medication. Interview revealed "(CM#7) admitted she was aware the ACT team was bringing in the medication," but did not recall CM #7 stating she had notified the clinical team, and there had been "no notes from the meeting" about delivery of the medication to the facility.

Interview with a psychiatrist, MD #8 on 09/19/2019 at 1206 revealed he recalled Patient #1 and had been made aware there was concern that she had not received the Invega injection during the time frame it was due. Interview revealed the Invega intramuscular form was not on the hospital formulary and when a medication was not on the formulary another medication would be substituted or the medication would be stopped. Interview revealed the Invega was expected to be continued and Patient #1 had been started on the oral short acting form on 07/01/2019 in order to maintain a therapeutic blood stream level of medication until the long acting injectable form was due and available. Interview revealed the medication had been delivered to the facility and CM #7 had been notified by the ACT team, but the information had not been passed on to the inpatient therapy team, and MD #8 had not received notification that the medication had been delivered to the facility. Interview revealed, because of the delay, Patient #1 would need to undergo a reinitiation regimen for Invega. MD #8 stated it should not have happened and "it was not standard of care for us."

Interview on 09/17/2019 at 1405 with a nurse practitioner, NP #1 who worked for the ACT team revealed a team member made arrangements to pick up the previously delivered Invega injection from the facility on 07/12/2019 at 1535, and Patient #1 had begun a re-initiation regimen for the medication because of Patient #1's delay receiving the Invega injection. NP #1 indicated the Invega injection had been due the day it was delivered on 06/25/2019.

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