HospitalInspections.org

Based on review of facility policies and procedures, observation and interview with staff (EMP), it was determined that the facility failed to ensure that medications/biologicals were maintained in accordance with approved facility ' s policies and procedures.

Findings include:

Review on October 16, 2018, of nursing policy " Medication Administration " revisited August 2015, revealed " Purpose: ... To ensure preparation, administration and documentation of medications as prescribed by the ordering physician ... 6. Medications are never to be pre-poured ... 9. The medications are poured and administered by the same nurse ... "


Observations on October 16, 2018, of the EAC (extended acute care unit) medication refrigerator at 12:10 PM revealed a reconstituted vial of Geodon, Inj 20 mg/ml, SDV (single dose vial) Further observation revealed the bottle was dated 10/15/18. There was no documented evidence for the person that reconstituted the medication.

Interview with EMP5, on October 16, 2018, at 12:15 PM confirmed the date written on the vial was the reconstitution date. Further interview with EMP5 confirmed the medication was " probable mixed and not given yesterday. " Further interview with EMP5 confirmed the beyond use date after reconstitution is 7 days.

Interview on October 16, 2018, at 2:00 PM with EMP7 confirmed it is not the policy of the facility to save injectable medications that were reconstituted and not administered right away. Further interview with EMP5 confirmed the medication should have been discarded immediately if was not administered.

The Physical Environment Condition was found to be out of compliance during a Life Safety Survey completed on October 22, 2018. Further details are outlined in the Division of Life Safety Survey Report

Based on medical record review, policy review, and interview, the facility failed to provide psychosocial assessments that met professional social work standards. These assessments failed to include conclusions from the data documented in the psychosocial assessment and failed to include individualized treatment recommendations that described anticipated social work roles during inpatient treatment and discharge planning for ten (10) of ten sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10). The assessment listed "Anticipated course of treatment" for the entire treatment team. Social work interventions are listed only as generic non-individualized discipline functions in check boxes. These failures result in a lack of professional social work treatment services and/or lack of input to the treatment team to assist in the care of the patient during hospitalization.

Findings:

Medical Records

1. Patient A1's psychosocial assessment dated 8/18/18 listed only the following generic "Social Work role in treatment and discharge planning":
- "Meet individually to practice skills/problem solving,
- Obtain collateral information,
- Coordinate outpatient provider/support person inclusion in treatment/discharge planning,
- Meet individually to develop continuing care planned coordinate aftercare appointments" [sic]

2. Patient A2's psychosocial assessment dated 10/2/18 listed only the following generic "Social Work role in treatment and discharge planning":
- "Meet individually to practice skills/problem solving,
- Obtain collateral information,
- Coordinate outpatient provider/support person inclusion in treatment/discharge planning,
- Meet individually to develop continuing care planned coordinate aftercare appointments" [sic]
- "Facilitate family/support person