HospitalInspections.org

Based on a review of patient rights and facility policy, and medical records (MR) and staff interviews (EMP), it was determined that the facility failed to protect and promote each patient's right to receive medications as prescribed for one of one medical record reviewed (MR1).

Findings include:

A review of the facility's Patient Rights, last reviewed July 2014, revealed, "...Code of Ethics, Patient Care...11. Staff members provide competent patient care within the boundaries of their job description. 12. Staff members promote and ensure safety. ..."

A review of the facility policy "Medication Administration" last reviewed March 2015, revealed, "...Right Patient: Verify the patient by using two methods of identification and check wristband (name and birthdate). Name alert stickers are available for use when names are the same or similar. Right Medication: Verify identification of each medication and dose during the initial check against the MAR (Medication Administration Record) and again prior to actual administration. High alert medications and the similar/sound alike medications require a second check by a nurse. Do not borrow medications from another patient's bin, use medications from home without an order and verification by a member of the medical staff or pharmacist, or administer a non-urgent medication before pharmacist or MD review. Right Dose: Verify identification of each dose during the initial check against the MAR prior to administration. ... "

A review of MR1's physician orders dated 11/10/15, at 11:44 AM revealed, "...New order Methadone HCl- 10 mg TAB (tablet), PO (by mouth). Take four (4) tablets daily provided by Methadone program..."

Further review of MR1's orders, both dated 11/10/15, at 3:00 PM revealed written at the bottom, "Clarify! 40 mg Liquid... " and "...New Order Methadone HCl- 10 mg /5 ml Sol, PO. Take forty (40) mg Solution Each Morning/change from tablet to liquid form...Discontinued Methadone HCl- 10 mg TAB, PO..."

A review of MR1's Medication Administration Record revealed the administration of Methadone 40 mg at 6:00 PM on 11/10/15.

A review of nursing documentation in MR1 revealed that on 11/10/15, at approximately 5:50 PM the patient went to the medication window and requested Methadone, which was administered at the time of the request. At 6:20 PM it was realized when discussing Methadone with another nurse that the patient received the incorrect dose of Methadone. A Registered Nurse (RN) and the patient's RN confirmed with the patient that Methadone was administered. The RN notified the on call psychiatrist. The patient's vitals were taken (BP 114/90, P 88, O2 98%, R 16). Patient was information that the wrong dose of Methadone was administered. Patient was instructed to report any concerns or complaints to staff. The physician ordered vital signs to be taken every four hours for closer observation."

Further review of MR1's nursing documentation revealed, "11/10/15 10:30 PM Pt vital signs were assessed at 10:20 PM BP 110/82, HR 72, Temp 98, RR 16. Pupils are pinned, but reacting to light. Pt (patient) appeared sedated but was easily aroused and oriented to person, place and time. The patient's medications were held due to sedation." Patient wanted to stay up but the RN encouraged and escorted the patient to bed.

Further review of facility documents revealed that on 11/11/15, at 12:10 AM the crisis alarm was activated. Staff doing rounds found patient with labored breathing and skin discolored. 911 called and patient's vitals were taken (BP 88/64, Pulse Ox 36, HR 125). Oxygen was administered per nasal airway. Patients pulse ox increased to 96 but patient remained unresponsive. Ambulance arrived and Narcan administered. Patient was transferred to a local hospital.

An interview conducted on 1/27/16, at 11:10 AM with EMP3 revealed another patient was prescribed Methadone. The Methadone was stored in the medication room. This patient was prescribed 175 mg of Methadone. MR1 was prescribed 40 mg of Methadone. MR1's Methadone was not in house and was in the process of being picked up at the clinic off site. MR1 presented to the medication window for the administration of Methadone. EMP7 administrated the wrong medication to the patient. Patient was given 175 mg of Methadone and not 40 mg, as prescribed. This medication administration error was not discovered until the 40 mg of Methadone arrived at the medication room.

Further review of facility documentation revealed a crisis alarm was called at on 11/11/15, at 12:10 am and staff responded with a code cart. Oxygen was administered, but Narcan (medication to treat narcotic overdose in an emergent situation) was not given, even though Narcan was available on the code cart.

Further interview with EMP3 on 1/27/16, at 11:10 AM revealed, "In retrospect, the Narcan should have been administered. The physician was present. Everyone is in agreement that the Narcan should have been administered." EMP3 confirmed there was no policy to address Narcan availability or emergency administration. Additionally, EMP3 confirmed that EMP7 did not properly follow the "Medication Administration" policy and failed to administrator the right medication to the patient.

An interview conducted on 1/28/16, at 10:15 AM with EMP10 revealed, "Staff was not aware that Narcan was available on the code cart. We did not in-service all staff."

Based on review of facility policy, medical records (MR) and employee interviews (EMP), it was determined that the facility failed to obtain informed consent for psychiatric medications for four of 12 medical records reviewed (MR6, MR7, MR8, and MR9).

Findings include:

A review of the facility policy "Montgomery County Emergency Service Informed Consent Policy" last revised April 30, 2014, revealed, "...Procedure: 2. Informed consent about medication includes the physician/nurse practitioner's description of appropriateness of medication, desired effects, possible side effects, and risks and benefits associated with the proposed treatment, including alternative treatments and foregoing treatment. The patient will sign an informed consent form for psychotropic medications and receive documentation on the characteristics of medications and possible side effects at his/her request. ..."

A review of MR6, MR7, MR8, and MR9 on 1/28/16, revealed multiple physician's orders for psychotropic medications. However, the medical records did not include a patient signed "Informed Consent for Psychiatric Medications" form.

An interview conducted on 1/28/16, at 9:50 AM with EMP11 confirmed that it was the facility's policy to obtain the patient's consent regarding psychiatric medications and that MR6, MR7, MR8, and MR9 did not include consent for psychotropic medications.

Based on a review of facility policy, medical records (MR), and employee interviews (EMP), it was determined that the facility failed to inform each patient of visitation rights for ten of 12 medical records reviewed (MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, and MR12).

Findings include:

A review of the facility policy "Montgomery County Emergency Service Visitors Policy/Procedure" last revised March 2011, revealed, "Policy It is our policy to encourage and support interactions among family members and significant others for patients who have been admitted to MCES. ..."

A review of MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, and MR12 on 1/28/16, revealed no documentation that the notice of the patient's visitation rights were provided to the patient/patient representative.

An interview on 1/28/16, at 9:55 AM with EMP11 confirmed that MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, and MR12 did not include documentation that the patient's visitation rights were provided to the patient/patient representative.

Based on a review of facility documents and staff interviews (EMP), it was determined that the facility failed to provide evidence that each quality indicator selected was related to improved health care, provide evidence that the frequency of data collection was specified for each quality indicator, provide evidence that data collected was compared to performance benchmarks, and provide evidence that the governing body approved the frequency of data collection.

Findings include:

Review of the facility's "Performance Improvement Plan 2015" revealed, "... The Performance Improvement Committee is responsible for coordinating and executing the components of the performance Improvement Plan. ... Delineating authority for departmental monitoring and evaluation activities ... monitors problem resolution ... Communicating information from the monitoring and evaluation activities. ..." The plan did not specify that each quality indicator selected was related to improved health care, that the frequency of data collection was specified for each quality indicator, that data collected was compared to performance benchmarks, and that the governing body approved the frequency of data collection.

An interview on 1/27/16, at 2:20 PM with EMP4 confirmed that the facility failed to provide evidence that each quality indicator selected was related to improved health care, provide evidence that the frequency of data collection was specified for each quality indicator, provide evidence that data collected was compared to performance benchmarks, and provide evidence that the governing body approved the frequency of data collection.

Based on a review of facility policy, a tour of the medication room, and employee interviews (EMP), it was determined that the facility failed to properly discard expired medications.

Findings include:

A review of the facility policy " Expired or Altered Drugs" last revised March 2015, revealed, "Policy: It is the policy to never administer any expired drugs to any patient. ..."

A tour of the Nursing Unit Medication Room on 1/28/16, revealed the following medications and supplies were expired: A 5 ml vial of Fluvirin (flu vaccine) that expired on 1/25/16; a 0.5 ml vial of Tuberculin solution (used to help diagnose tuberculosis infections) that expired on 1/14/16; and four Bacti-swab culture kits (used to diagnose bacterial infections) that expired 1/28/13.

An interview conducted on 1/28/16, at 12:15 PM with EMP3 confirmed that the above medications and supplies were expired and that the facility failed to properly dicard the expired medications and supplies.