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Based on observation, record review and interview, the hospital failed to ensure pharmacy services were delivered under the supervision of the pharmacist-in-charge as evidenced: 1. by hospital staff failing to label intravenously (IV) administered antibiotics and maintenance IV fluids per accepted pharmacy standards for 3 of 3 patients with IVs; and 2. by a lack of competency evaluation for the drug room supervisor and other hospital staff who performed pharmacy procedures.

Findings:

Observations conducted, 07/09/19, 9:15-10:00 AM, revealed 3 of 6 patients (#s 1, 3, 4) had IV antibiotics (#1, 4), and IV fluids (#3) infusing. Observations of patient #s 1 and 4's IV piggy back antibiotics revealed the information on the piggy back bag was the name and strength of the medication, the date and time it was hung for infusion; there failed to be the patients name. Observation of patient #3's IV bag revealed there lacked a label with the patient's name, date and time it was hung.

Based on review of pharmacy standards labeling of all drugs and biologicals should include at a minimum: the patients name, name of drug/medication, strength of drug/medication, quantity of the drug dispensed, and the expiration date.

Review of Staff #? personnel file revealed there failed to be documented evidence the pharmacist-in-charge performed a competency evaluation or provided documented training relative to pharmacy services.

Review of Staff #s? personnel files revealed there failed to be documented evidence the pharmacist-in-charge performed competency evaluations and provided training relative to pharmacy services.

Based on record review and interview, the hospital failed to ensure the consultant pharmacist-in-charge evaluated and documented investigations into medication errors as evidenced by a lack of documentation of involvement.

Findings:

Review of the Quality Assurance Performance Improvement (QAPI) data provided, dated July 2018-June 2019, revealed medication errors were reported by numbers only; there lacked documented evidence the pharmacist-in-charge was active in the investigation and resolution of the medication errors.

Review of QAPI data, Pharmacy and Therapeutics Committee meetings (June 2018-June2019), and the Medical Staff meeting minutes, June 2018-June 2019, revealed medication errors were reported in numbers only. There lacked documentation of investigation as to the possible causes and action plan to help avoid future errors.

Interview, 07/09/19 at 4:00 PM, with Staff #E (drug room supervisor) revealed the pharmacist-in-charge received the medication errors via reports generated by the automated drug dispensing machine. Once the pharmacist-in-charge received the medication error, Staff #E would be notified and then forward them to Staff #B for investigation and resolution.

Interviews, 07/10/19 at 9:00 AM, with Staff #s A, B, and E confirmed the pharmacist-in-charge was not actively involved in investigating and the resolution of the medication errors.

Based on record review and interview the critical access hospital failed to evaluate the quality and appropriateness of services affecting patient and safety by not documenting action plans for each indicator identified by the hospital.
Findings:

A review of the Quality Assurance/Performance Improvement (QA/PI) Meeting Minutes for 07/2018, 10/22/18 and 01/21/19 revealed the quality coordinator failed to document action plans for each indicator.

On 07/09/19 at 2:00 PM Staff #B stated she was the quality coordinator and had begun her job in 05/2019. Staff #B confirmed that the QA/PI did not have a plan of action for each indicator to improve the problems or potential problems.