HospitalInspections.org

Based on medical record review, interview and review of policy and procedure, the hospital failed to review, verify and dispense Patient Identifier (PI) # 1's medication brought from home prior to administration of medication. The hospital also allowed a family member to administer medication to PI # 1.

Findings include:

Medical Record Review revealed: Female admitted to the hospital on 6/28/15 with diagnoses to include:
1. Narcotic induced coma.
2. Diastolic heart failure.
3. History of Hypertension.
4. End of life care with DNR (Do Not Resuscitate) in effect.

A Physician's Order dated 6/29/15 at 4:15 AM revealed..."Pt. (patient) may take all home med (medication) to be administered by (Name of Hospice) or per (by) family member."

During an interview on 9/15/15 at 5:30 PM a Registered Nurse/ Employee Identifier (EI) # 2 (assigned to care for PI # 1 on 6/29/15) stated PI # 1's family brought PI # 1's home medication to the hospital and she witnessed a family member administer Atropine drops to PI # 1.

During an interview on 9/16/15 at 11:37 the Chief Nursing Officer (CNO)
/ EI # 1, stated hospice nurses may not administer medications to hospital patients. Home medications for patient use may be brought to the hospital for use by a patient, but must be reviewed, approved and dispensed by the hospital pharmacy. The CNO confirmed the physician should not have given an order for medication to be given to PI # 1 by the family or hospice nurse on 6/29/15. The CNO also confirmed PI # 1's medication brought from home by the family was not reviewed by the hospital pharmacy.

Policy: Patient's Own Medication Usage
Department: Pharmacy, Nursing, Physical Therapy
Effective: 9/23/05
Revised: 4/28/09

Policy: " In most cases, the utilization of a patient's own medication is discouraged... Medications brought in by the patient to be utilized during their stay must meet the following conditions:

Drugs have been ordered by a person who is a credentialed licensed independent practitioner holding privileges at this institution. The medications to be utilized must be individually noted with their corresponding strengths and directions for administration...

The contents of the containers have been examined, positively identified and the integrity evaluated by the patient's physician and/or the hospital pharmacist.

Procedure:
A patient's own medication may be dispensed when a non-formulary medication is ordered by the physician...permitted by law and permitted by the organization to prescribe medications when all of the following conditions are met:

Medications are ordered by the patient's physician...and an order is entered on the patient's chart, indicating:

a. Name of drug
b. Strength of drug and route
c. Dose schedule
d. Rationale for drug use

Medications have been examined by the physician or pharmacist for positive identification, integrity and correct labeling. If the medication is deemed acceptable, the pharmacy will call nursing to document in the patient's chart that the pharmacy will be dispensing the patient's own medication..."