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Based on staff interview and record review, the hospital failed to report an event that could have contributed to patient neglect, to APS (Adult Protective Services) within 48 hours in accordance with Vermont State Statute Title 33 Chapter 69 "Reports of abuse, Neglect and Exploitation of Vulnerable Adults". Findings include:

Per staff interview the facility identified, during the process of conducting an internal review, a concern related to potential drug diversion by a staff member. RN (Registered Nurse) #1 stated, during interview at 11:11 AM on the morning of 7/28/14, that s/he had brought an oxycodone (narcotic pain medication) pill to the room of Patient #1 on 3/6/14, and left the pill in a medicine cup on the bedside table, near the patient and in the presence of the patient and Staff Member #1 (whose scope of practice did not include medication administration), while the RN left the room for a short period to retrieve water for the patient. The RN stated that when s/he returned to the room it appeared the oxycodone had been replaced, in the medicine cup, with a different pill and the oxycodone was never found. The unit Nurse Manager, who was present during the same interview, stated that, although s/he had been made aware of the incident of 3/6/14, no investigation was conducted. S/he stated that it was not until 4/21/14 when Staff Member #1 was observed, on several occasions involved in what appeared to be drug seeking activity, that an investigation was conducted and the staff member suspended from duty. The Director of Accreditation and Regulatory Compliance confirmed that although the facility recognized and acted upon the concern of drug diversion on 4/21/14, and reported to the Office of Professional Regulation, the report to APS, which did not occur until 6/30/14, was not made in a timely manner.

Based on observations, staff interviews and record review the facility failed to assure that all staff utilized the established event reporting system to identify a potential adverse event and opportunity for improvement; and failed to fully analyze, develop and implement actions and mechanisms for learning throughout the hospital, following an identified adverse event. Findings include:
Per staff interview the facility identified, during the process of conducting an internal review, a concern related to potential drug diversion by a staff member. RN (Registered Nurse) #1 stated, during interview at 11:11 AM on the morning of 7/28/14, that s/he had brought an oxycodone (narcotic pain medication) pill to the room of Patient #1 on 3/6/14, and left the pill in a medicine cup on the bedside table, near the patient and in the presence of the patient and Staff Member #1 (whose scope of practice did not include medication administration), while the RN left the room for a short period to retrieve a cup of water for the patient. The RN stated that, upon return to Patient #1's room with the water, s/he noted the pill in the medicine cup looked different from the oxycodone pill that s/he had placed there. S/he stated s/he asked Staff Member #1 what had happened to the oxycodone pill and, although Staff Member #1 replied that it may have fallen on the floor, it was not found. RN #1 stated that s/he identified the pill that had replaced the oxycodone, as Tramadol (a non-narcotic pain medication) which was disposed of, and another oxycodone was obtained and administered to Patient #1. S/he stated the concern was reported, immediately to RN #2, who was the unit Charge Nurse at the time. RN #2 stated, during interview at 2:00 PM on 7/29/14, that s/he had reported the incident to the unit Nurse Manager. The unit Nurse Manager, who was present during each of the interviews with RN #1 and RN#2, stated that, although s/he had been made aware of the incident of 3/6/14, and although the evidence would suggest a possible attempt at diversion of the oxycodone, an event report was not completed and no investigation was conducted at that time. The Nurse Manager stated that it was not until 4/21/14 when Staff Member #1 was observed, on several occasions, involved in what appeared to be drug seeking activity, with his/her hands inside the needle disposal container located in the med room, that an investigation was conducted and the staff member suspended from duty. S/he further stated that as a result of the incidents education had been provided to staff members on the unit regarding the importance of event reporting as well best practice for medication administration, including keeping meds with you at all times until administered or disposed of.
The Director of Pharmacy Services stated, during interviews on the afternoons of 7/28/14 and 7/29/14, respectively, that the facility's policy for disposing of medications included: disposal of all controlled substances down the drain; disposal of other medications into a med disposal container located in the locked med room on each unit and disposal of fentanyl (narcotic pain medication) patches into the needle disposal containers. Per review, this information was reflected in the facility policies The Disposal and Destruction of Unwanted or Expired Drugs or Agents (Inpatient and Outpatient), dated 6/23/14.
RN #1 confirmed, during interview on the morning of 7/28/14, that his/her practice was in accordance with the facility policy for drug disposal. However, Nurse #2 stated, during interview at 2:00 PM on 7/29/14, that although s/he was aware "some nurses" disposed of controlled substances down the drain, it was his/her practice to dispose all medications, including controlled substances, into the med disposal container.
Per observation, during tour of 3 separate inpatient units on the morning and afternoon of 7/29/14, the med disposal containers, as well as needle disposal containers were located inside the locked med rooms on each unit, unsecured and the contents readily accessible to anyone with access to the room. In addition, in the med room on one unit there were medications stored in unsecured individual bins labeled with patient names, which included: multi-dose prescription mouth wash, Flonase nasal spray and ophthalmic solution.
Per interview, the unit Nurse Manger stated that although Staff Member #1, did not administer medications, s/he did have authorized access to the med room for the purpose of obtaining other supplies. The Nurse Manager acknowledged that, despite the evidence of attempted drug diversion by Staff Member #1 who had been observed involved in drug seeking activity with his/her hand in the needle disposal container in the med room, no changes had been made to assure security of those disposed medications. The Pharmacy Director also confirmed that, although discussion had taken place regarding alternate medication disposal processes, no changes to the process had been made to date. The Director of Accreditation and Regulatory Compliance acknowledged, during interview on the afternoon of 7/30/14, that although education had been provided to nursing staff on the unit on which the incidents had occurred, that chosen mechanism for learning had not been implemented on a hospital wide basis.

Based on observations, staff interview and record review the facility failed to assure that all drugs and biologicals were stored in a secured manner following an event in which there was evidence of attempt at drug diversion by a staff member. Findings include

Per staff interview the facility identified, during the process of conducting an internal review, a concern related to potential drug diversion by a staff member. RN (Registered Nurse) #1 stated, during interview at 11:11 AM on the morning of 7/28/14, that s/he had brought an oxycodone (narcotic pain medication) pill to the room of Patient #1 on 3/6/14, and left the pill in a medicine cup on the bedside table, near the patient and in the presence of the patient and Staff Member #1 (whose scope of practice did not include medication administration), while the RN left the room for a short period to retrieve water for the patient. The RN stated that, upon return to Patient #1's room with the water, s/he noted the pill in the medicine cup looked different from the oxycodone pill that s/he had placed there. S/he stated s/he asked Staff Member #1 what had happened to the oxycodone pill and, although Staff Member #1 replied that it may have fallen on the floor, it was not found. RN #1 stated that s/he identified the pill that had replaced the oxycodone, as Tramadol (a non-narcotic pain medication) which was disposed of, and another oxycodone was obtained and administered to Patient #1. S/he stated the concern was reported, immediately to RN #2, who was the unit Charge Nurse at the time. RN #2 stated, during interview at 2:00 PM on 7/29/14, that s/he had reported the incident to the unit Nurse Manager. The unit Nurse Manager, who was present during each of the interviews with RN #1 and RN#2, stated that, although s/he had been made aware of the incident of 3/6/14, and although the evidence would suggest a possible attempt at diversion of the oxycodone, an event report was not completed and no investigation was conducted at that time. The Nurse Manager stated that it was not until 4/21/14 when Staff Member #1 was observed, on several occasions, involved in what appeared to be drug seeking activity, with his/her hands inside the needle disposal container located in the med room, that an investigation was conducted and the staff member suspended from duty.
The Director of Pharmacy Services stated, during interviews on the afternoons of 7/28/14 and 7/29/14, respectively, that the facility's policy for disposing of medications included: disposal of all controlled substances down the drain; disposal of other medications into a med disposal container located in the locked med room on each unit and disposal of fentanyl (narcotic pain medication) patches into the needle disposal containers. Per review, this information was reflected in the facility policies: The Disposal and Destruction of Unwanted or Expired Drugs or Agents (Inpatient and Outpatient), dated 6/23/14. The policy Security of Medications, dated 6/4/14, stated: "......If there is evidence of tampering or diversion, or if medication security otherwise becomes a problem, the hospital is expected to evaluate its current medication control policies and procedures, and implement the necessary systems and processes to ensure that the problem is corrected, and that patient health and safety are maintained."

RN #1 confirmed, during interview on the morning of 7/28/14, that his/her practice was in accordance with the facility policy for drug disposal. However, Nurse #2 stated, during interview at 2:00 PM on 7/29/14, that although s/he was aware "some nurses" disposed of controlled substances down the drain, it was his/her practice to dispose all medications, including controlled substances, into the med disposal container.
Per observation, during tour of 3 separate inpatient units on the morning and afternoon of 7/29/14, the medication disposal containers, as well as needle disposal containers were located inside the locked med rooms on each unit, unsecured and the contents readily accessible to anyone with access to the room. In addition, in the med room on one unit there were medications stored in unsecured individual bins labeled with patient names, which included: multi-dose prescription mouth wash, Flonase nasal spray and ophthalmic solution.
Per interview, the unit Nurse Manger stated that although Staff Member #1, did not administer medications, s/he did have authorized access to the med room for the purpose of obtaining other supplies. The Nurse Manager acknowledged that, despite the evidence of attempted drug diversion by Staff Member #1 who had been observed involved in drug seeking activity with his/her hand in the needle disposal container in the med room, no changes had been made to assure security of those disposed medications. The Pharmacy Director also confirmed that, although discussion had taken place regarding alternate medication disposal processes, no changes to the process had been made to date.