HospitalInspections.org

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Based on review of medical records, hospital policies/procedures, Medical Staff Bylaws and staff interviews during the Federal Allegation Survey, it was determined that the Governing Body did not develop and implement policies for the medical staff, nursing staff and pharmacy staff to ensure patient received continued pharmaceutical therapies after the automatic 30 day discontinuation of medications.

Findings:

See citation in
482.22 Medical Staff A-0353
482.23 Nursing Services A-0406
482.25 Pharmaceutical Services A-0490
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Based on review of medical records, hospital policies, Medical Staff Bylaws and staff interviews during the Federal Allegation Survey, it was determined that the Medical Staff did not develop and implement policies to ensure review of the discontinued pharmaceutical therapies automatically stopped after the thirty (30) day automatic stop order of medications by Pharmacy. (Patients #6 and #15).

Findings:

Review of the medical records for Patient #6 and Patient #15 revealed that the physicians ordered medications that automatically expired and were stopped after thirty (30) days according to the pharmacy policy. There is no documented evidence that the physicians intentionally discontinued the medications.

There is no indication that the nursing staff conferred with the physician when the medication ordered was stopped and no documented evidence the pharmacy staff communicated with the physician when the physician did not issue additional orders, resulting in the patient not receiving the prescribed treatments.

Review of the Bylaws dated 09/2012, revealed that a practitioner's routine orders shall be reproduced in detail on the order sheet. All orders for treatment shall be in writing and all orders are placed on hold when a patient goes to surgery. Requirements for medication orders and intravenous infusions are included in the pharmacy policies. However, there is no explanation of the pharmacy policy regarding automatic stop orders or required actions by the physician.

Review of the current pharmacy policy entitled "Automatic Stop Orders for Medication" revealed that all routine drug orders will be valid for no longer a period of thirty (30) days. In order for the stop date to be continued the physician must write an order. A patient specific "Order Approaching Expiration Report" is placed on each patient's chart but there is no requirement for the physician to complete or acknowledge the form.

Additionally the pharmacy policy states that an "Expired Orders Report" is also printed on each Nursing Unit daily for the orders that expired the previous day but this does not include any actions to be taken by the pharmacist, nurses, or physicians.

This was confirmed by the Assistant Vice President of Performance Improvement, Pharmacy Supervisor and Clinical Nurse Educator.

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Based on record review and staff interviews during a Federal Allegation Survey it was determined that the nursing staff did not have a policy for (a) the "Orders Approaching Expiration-Renewal Action Form" or the "Expired Order Report" and (b) to communicate with the physician when medications were automatically stopped, resulting in the patient not receiving an appropriate therapeutic medication regimen (Patients #6 and #15).

Findings:

Review of the medical record for Patient #15 revealed the patient had a known history of coronary disease and refractory seizure disorder on admission dated 07/10/12. The patient was evaluated by cardiology who prescribed oral Cordarone 200 mg twice a day on admission. Neurology also evaluated the patient and recommended continuing the anti-convulsive medications taken prior to admission and started the patient on Tegretol and Lamictal (Tegretol 200 mg PO four times daily and Lamictal 250 mg PO twice daily) .

Review of the Medication Administration Record (called "MAK" by facility staff) indicated that the patient did not receive the cardiac medicine, Cordorone, or the anti-convulsant medications, Tegretol and Lamictal, in the afternoon or evening on 10/01/12, all day on 10/02/12 and 10/03/12 and the morning of 10/04/12 for a total of three days.

There is no documented evidence on record review that the nursing staff conferred with the physician to obtain an order to continue or discontinue the automatically stopped medications.

There is no documented evidence that the physician renewed these anti-convulsant medications or cardiac medications, that were automatically stopped on 09/30/12, until the afternoon on 10/04/12.

Similar findings were found on review of the medical record for Patient #6.

Review of the nursing policy entitled "Medication Administration" dated 06/2012 revealed no instructions on automatically stopped medications. There is no reference for implementing the "Orders Approaching Expiration-Renewal Action Form" or the "Expired Order Report".

Interviews during the day on 10/17/12 with the Assistant Vice President of Performance Improvement, Director of Nursing for Professional Development and a Clinical Nurse Educator revealed there is no current nursing policy explaining the intended use of the "Expired Order Report" generated and sent daily to the Nursing Units. There is also no nursing policy indicating the nurse's responsibility if a physician fails to address the "Orders Approaching Expiration-Renewal Action Form" that is placed in the patient's medical record.
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Based on record reviews and staff interviews during a Federal Allegation Survey it was determined that the pharmaceutical service failed to establish a procedure in consult with the physician to ensure that drugs and biologicals automatically stopped after thirty (30) days were reviewed and reordered or discontinued, to meet the patients' therapeutic medication regimens.

Findings:

Review of the medical record for Patient #15 revealed the patient had a known history of coronary disease and seizure disorder. The patient was started on Cordarone, Tegretol and Lamictal on 07/10/12. The medications where then automatically stopped according the pharmacy policy on 09/30/12.

Review of the Medication Administration Record (called "MAK" by facility staff) indicated that the patient did not receive the medications in the afternoon or evening on 10/01/12, all day on 10/02/12 and 10/03/12. There is no documented evidence that the physician renewed these medications until 10/04/12.

There was no "Orders Approaching Expiration" Form in the patient record which was confirmed by the Assistant Vice President of Performance Improvement and Director of Nursing for Professional Development.

Review of the medical record for Patient #6 revealed the patient was admitted on 07/01/12 and discharged on 08/19/12. The physician ordered Bacitracin ointment topically twice a day at 6:00 PM on 07/08/12. The nursing Medication Administration Record revealed that the medication was applied as ordered until 08/07/12, at which time the medication was automatically stopped according to the pharmacy policy resulting in the patient not receiving the medication for the next 12 days. There is no documented evidence that the physician intentionally discontinued the medication and no indication that the nursing staff or pharmacy staff communicated the automated stop order to the physician.

Review of the pharmacy policy entitled "Medication Ordering: Order Management" dated 09/18/12 reveals there is no reference to the automatic stop order for medication after thirty (30) days.

Review of the pharmacy policy entitled "Medication Stop Dates" dated 02/2012 revealed all routine drugs shall be valid for no longer then thirty (30) days and the prescriber must write an order to continue the medication but there is no requirement for a pharmacist to consult with the physician if this does not occur prior to discontinuing the medications.

An interview with the Pharmacy Supervisor during the afternoon of 10/17/12 revealed that the "Order Approaching Expiration" Report and the "Expired Orders" Report is automatically generated and placed on each patient's chart by the unit secretary but there is no current process by the pharmacy staff to ensure the information is reviewed by the physician.
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Based on observation and staff interview during the Federal Allegation Survey, it was determined that the facility failed to ensure laboratory supplies stored on a Nursing Unit were maintained in an acceptable level of quality or safety.

Findings:

During the inspection of the locked Medication Room on 2 Central at 4:00PM on 10/18/12, the surveyor identified expired laboratory supplies in an unlocked cabinet. The cabinet contained one (1) box of twenty-two (22) blood vacutainer vials for obtaining CBC, Lot #1119960, expiration date 09/2012, a 6.5cc bottle of Slide Fixative Lot #42410 that expired on 04/13/12 and a box of nineteen (19) Para-Safe Ova and Parasite Stool Specimen Collector vials Lot #38610 that expired on 09/17/12.

These observations were confirmed by both the Nurse Manager and the Assistant Vice President (AVP) of Performance Improvement present on the tour. On interview the Nurse Manager did not know why the supplies were being stored in the medication room.

An interview on 10/18/12 at 4:15PM with the AVP revealed she had spoken with the Laboratory Supervisor who stated that the laboratory technicians do keep supplies on the Nursing Unit and are responsible for checking the expiration dates but they do not store items in the medication rooms because they do not have access to them.