HospitalInspections.org

Based on observation and interview, the facility failed to ensure medications dispensed from automated medication dispensing system machines were not stored and dispensed through other means, and failed to ensure dangerous medications were kept in labeled bins, separate and distinct from other medications in the automated medication dispensing system. This has the potential to affect all patients in the facility.

Findings include:
In the afternoon of 07/10/12 from 1:45 P.M. to 2:25 P.M., a tour of the unit called Four West was conducted with the Director of Pharmacy. The surveyor observed a box secured to the wall that contained patient medications. In an interview during the tour, the Director of Pharmacy explained if medications are not stocked in the automated medication dispensing system, then pharmacy delivers them to the box.
Observation of the Four West medication storage wall bin on 07/10/12 between 1:45 P.M. and 2:25 P.M. revealed the presence of the patient's home medications which included Cymbalta (an antidepressant medication) along with a bag of other home medications. Interview, during the tour, with the Director of Pharmacy revealed when patients brought their home medications with them to the hospital the hospital policy and procedure, was to attempt to send them home with family. If this is not possible to send them to the main pharmacy to be held until the time the patient was discharged or the medications could be released to family to take home. This was to avoid the dual administration of medications. The Director of Pharmacy verified these medications should not be in the wall bin but should have been sent to pharmacy.

During the tour, a container in the box labeled for patient room 432, bed 2, was observed to contain four medications. The Director of Pharmacy, during the tour, confirmed those medications were stocked in the automated medication dispensing system, and couldn't explain why they were being kept in the box.

Inspection of the facility's fourth floor medication room on 07/10/12 at 2:18 P.M. revealed an automated medication dispensing machine contained a previously opened box of one milligram per milliliter box which contained a prefilled syringe of injectable Atropine one milligram per milliliter (used to rapidly raise blood pressure and heart rate). Interview with the Director of Pharmacy, at the time of this observation, verified the presence of this emergency medication in an altered form and verbalized "that shouldn't be there, pharmacy will replace that."

On 07/10/12 at 2:40 P.M. a tour of the intensive care unit was conducted with the Assistant Director of Pharmacy and the Accreditation Manager. The surveyor observed in a medication cart, in a patient container, a previously accessed vial of heparin-a type of blood thinner-without any patient identifier information. In an interview the Accreditation Manager stated it may have been used in a procedure and should have been discarded immediately afterward.
During the tour of the intensive care unit, the unit's automated medication dispensing system was observed to have in its refrigeration section vials of pneumonia vaccines lying next to three vials of succinylcholine-a paralyzing agent that when administered inappropriately can result in death. Neither medication was in any type of labeled container.

This observation was confirmed by the Assistant Director of Pharmacy at 2:45 P.M.

Continued tour of the medication storage units revealed the third floor wall storage bin which serviced the 300 hall was found to contain a 25 milligram tablet of Metoprolol (anti hypertension medication) as well as a two ten milliEquivalent tabs of potassium chloride (mineral supplement). Both of these medications were available through the automated medication dispensing system and should not be stored in the wall bin medication storage areas according to the Director of Pharmacy. The Director of Pharmacy further verbalized the antihypertensive medication was stopped by the physician on 07/07/12. The Director of Pharmacy verbalized the automated medication dispensing system was reported as malfunctioning over the weekend but the concerns were resolved on 07/09/12. The pharmacy and nursing staff should have returned to using the automated medication dispensing system effective 07/09/12 and medications available by the automated medication dispensing system should be retrieved through that method. The medications in this wall bin should have been removed.

Tour of the five south floor medication storage areas revealed the medication wall bin to contain a 25 milligram tablet of hydralazine (used to treat hypertension) and a 100 milligram capsule of a commonly used stool softener. The wall bin also contained an unlabeled paper medication administration cup for an unspecified patient which contained a half tablet of hydrochlorothiazide (used to treat hypertension). Interview with the Director of Pharmacy on 07/10/12, at the time of this discovery revealed the hydralazine and stool softener were available in the automated medication dispensing system and should not have been in the wall bin.