HospitalInspections.org

22495

Based on policy and procedure review, review of the North Dakota Century Code, and review of the facility's Plan of Correction (POC) and mail revisit documentation/information, the Critical Access Hospital (CAH) failed to ensure staff distributed drugs and biologicals in accordance with professional principles for 15 weeks of 15 weeks reviewed (June 23, 2013-September 26, 2013). Failure to limit access to the hospital pharmacy to times of emergent circumstances, and ensure nursing staff obtained only the amount of medication to treat the immediate needs of the patient has the potential to create insufficient distribution, control, and accountability of medications.

Findings include:

The North Dakota Century Code, Chapter 61-07-01 "Hospital Pharmacy" stated,
". . . 61-07-01-05. Absence of pharmacist. . . . 3. Access to pharmacy. Whenever any drug is not available from floor supplies or night cabinets, and such drug is required to treat the immediate needs of a patient whose health would otherwise be jeopardized, such drug may be obtained from the pharmacy in accordance with the requirements of this section. One supervisory registered professional nurse and only one in any given eight-hour shift is responsible for removing drugs therefrom. The responsible nurse, in times of emergency, may delegate this duty to another nurse. . . ."

Review of the policy titled "PHARMACY USE BY NURSING PERSONNEL" occurred on 11/05/13. This policy, dated 07/10/13, stated,
"Policy: To ensure proper use of pharmacy and its contents by all nursing staff . . .
2. Pharmacy use:
(a). In an emergency and no pharmacy personnel present, nursing licensed personnel are to enter the Pharmacy.
(b). Medications may be removed from the Pharmacy using the following guidelines:
i. Injectables in multiple dose vials: One vial may be taken
ii. Injectables in single use ampules or pre-filled syringes: Take only enough to last until the next regularly scheduled Pharmacy hours.
iii. Topical medications: One unit may be taken
iv. Oral or rectal medications not in unit dose packaging: One dose may be taken.
v. Oral or rectal medications in unit dose packaging: Take enough to last until the next regularly scheduled Pharmacy hours. . . .
(d). Document on Pharmacy Medication sign out:
i. Complete all sections
1. Date
2. Medication (name of drug and # [number] taken)
3. Patient
4. Nurse (who removed med [medication])
5. Patient room number . . ."

Review of the facility's POC occurred on 11/05/13. Review of pages 12-14 stated, ". . . 3. The director of nursing and hospital pharmacist are responsible for the following: to review and revise as appropriate the policies and procedures titled "Pharmacy Use by Nursing Personnel" . . . to develop and communicate designated authorized personnel allowed access to the pharmacy during regular operations and emergency situations . . . Through the QA [quality assurance] program the director of nursing or her designee shall be responsible for the following . . . logging of medications removed and following proper protocol per current policy . . ."

Review of the "PHARMACY MEDICATION SIGN-OUT" forms, dated 06/23/13 through 09/26/13, occurred on 11/05/13 and showed the CAH nursing staff performed the following:
* Accessed the hospital pharmacy and removed medications 5 of 8 days in June; 20 of 31 days in July; 22 of 31 days in August; and 22 of 26 days in September
* Removed prescription and over the counter (OTC) medications for "stock" supply for the medication room adjacent to the nurses station
* Removed entire bottles of medications rather that the amount needed for the emergent situation
* Failed to identify the amount of medication removed for the emergent situation

Review of the mail revisit documentation lacked evidence the CAH corrected this issue as nursing staff continued to frequently enter the hospital pharmacy and remove multiple doses of medications in non-emergent situations. The CAH provided no further documentation or information to support staff recognized this noncompliance and implemented corrective action.

Failure to correct this issue permitted nursing staff to perform duties outside their scope of practice, and limited the pharmacist's ability to ensure safe medication practices and maintain responsibility for the overall administration of the pharmacy service. This failure limited the CAH's ability to provide pharmaceutical services in a safe and appropriate manner.