HospitalInspections.org

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Based on observation and interview the Critical Access Hospital failed to ensure pharmacy services were provided according to accepted professional principles for all medication dispensing/repackaging of medication for patient administration. This failure placed all patients at risk for potential medication errors.

Findings include:

Pharmacy regulation 68-7-11. Medical care facility pharmacy. (3) The designated registered professional nurse or nurses may enter the medical care facility pharmacy and remove properly labeled pharmacy stock containers, commercially labeled packages, or properly labeled prepackaged units of drugs. The registered professional nurse shall not transfer a drug from one container to another for future use, but may transfer a single dose from a stock container for immediate administration to the ultimate user.

Interview with Pharmacy Supervisor RN, staff K, and through observation revealed the practice of the pharmacy RN repackaging pills and tablets from the original container obtained directly from the supplier and transferring them for administration at a later date and time. Labels are affixed to the baggies with the patient name, medication name, dose, and administration time. The labeled baggies are then placed in the patient bins on the medication cart to be administered at the designated time by the floor RN. This practice is performed without direct oversight of the pharmacist.

A pharmacist is employed as a part time employee to oversee medication orders. The pharmacist is present in the hospital one day a week for approximately two hours at a time.

Facility pharmacy policy packaging and labeling states. "The director of pharmacy is responsible for the preparation and dispensing of all drugs and chemicals used in the hospital. ....All medications will be dispensed in unit of use packaging. When possible, medication will be purchased from manufacturers in unit of use packaging. When re-packaging is necessary, it must be done within the confines of the Pharmacy under the direct supervision of a Registered Pharmacist ..."

Observation on 7/7/16 at 10:30 of a bin in the pharmacy contained a bottle with a single pill labelled Zetia (a drug that lowers cholesterol in the blood).

Staff K interviewed on 7/7/16 at 10:30 confirmed that s/he had removed a single pill from the original container, labeled a single dose pill bottle and put the pill into that bottle for later use for Patient #1. Staff K said that most of the medications come in single dose packaging but that there are a few medications that come in multi dose bottle and s/he does transfer the pill from one container to another to dispense to a patient at a later time.
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