HospitalInspections.org

Based on observation, interview and record review the facility failed to ensure:


A. non narcotic medications and narcotics were reconciled, tracked as needed and pharmacy supervision was provided. They failed to ensure medication orders were accurate on patients being discharged. This deficient practice was found on 2 of 2 units (Medical-surgical and Psych unit).
Refer to tag A500 for additional information.


B. ensure non-narcotic medications and narcotics were reconciled and tracked in a manner to prevent diversion. They failed to ensure pharmacy supervision was provided on these medications on 1 of 1 unit (Psych unit).
Refer to tag A501 for additional information.

Based on observation, interview and record review the facility failed to ensure non narcotic medications and narcotics were reconciled, tracked as needed and pharmacy supervision was provided. They failed to ensure medication orders were accurate on patients being discharged. This deficient practice was found on 2 of 2 units (Medical-surgical and Psych unit).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:

*Medical/Surgical unit
During an observation on 07/21/2015 after 11:00 a.m., Staff #5 (charge nurse) prepared discharge paperwork on Patient #5. The paperwork was taken to Staff #6 who was the primary nurse taking care of Patient #5. Staff #6 went over the discharge instructions with Patient #5's family member. Staff #6 informed the family member Patient #5 would be taking his insulin Levemir once daily (long acting insulin which can last up to 24 hours). The family member interrupted and stated the medication was twice a day instead of once. Staff #6 scanned through the discharge paperwork and said you are right it is twice a day.
Review of the discharge instructions read as follows for the medication:
LEVEMIR FLEXPEN 100 UNIT/ML SQ 100 UNIT SOPN, 6 unit ONCE EVERY EVENING
LEVEMIR FLEXPEN 100 UNIT/ML SQ 100 UNIT SOPN, 10 units ONCE DAILY.
The orders were not written clear enough to determine how far apart to separate the doses of insulin (for example, one in am and one in pm).

*Psych unit

During an interview on 07/21/2015 after 12:15 p.m., Staff #8 reported they take patients home medications, inventory them, and locked them in the medication room. Observation of the storage area revealed the medications were being kept in a locked cabinet in the medication room. Staff #8 reported the medications are counted on admission and then again on discharge. The medication count should be logged on the form and witnessed by 2 people.
During an interview on 07/21/2015 after 1:50 p.m. Staff #8 reported the narcotics were treated the same way. The pharmacist was not being called to come and inventory or secure the medications. The narcotics were counted on admission and then again on discharge.
During an interview on 07/21/2015 after 2:40 p.m., Staff #9 (pharmacist) confirmed the medications were to be sent home with family or kept in the pharmacy until discharge. Staff #9 reported they were not monitoring the narcotics or other medications that were being kept in lock up on the unit.
There was no system in place to ensure medications were not diverted.

Review of the clinical record of Patient #1 revealed he was a 25 year old male admitted to the observation unit on 06/27/2015 with suicidal and homicidal thoughts.
According to a "Home Medication Inventory" dated 06/27/2015, Patient #1 had 26 tablets of Latuda (psychotropic agent) with him at admission. The medication was received from Patient #1 to be locked up.
According to the record Patient #1 was admitted into the adult psych unit on 06/29/2015. Patient #1 was discharged from the facility on 07/03/2015.
According to a "Home Medication Inventory" two nurses signed off as witnesses on 07/03/2015 for returning medication to Patient #1. There was no documentation of the medication being counted or documentation of the amount of medication returned to Patient #1.


Review of the clinical record of Patient #2 revealed he was a 54 year old male admitted on 05/09/2015 with chief complaints of suicidal and homicidal ideations.
According to a "Home Medication Inventory" dated 05/09/2015, Patient #2 had the following medications with him on admission:
*APAP/Codeine (the narcotic agent Tylenol with Codeine) 168 tablets;
*Orajel - one tube of the pain agent;
*Timolol Maleate - one bottle of eye drops used for glaucoma.
The medication was received from Patient #2 to be locked up.
According to the record Patient #2 was admitted into the adult psych unit on 05/11/2015. Patient #2 was discharged from the facility on (7 days later) 05/18/2015.
According to a "Home Medication Inventory" there was no documentation of the medication being counted on discharge or documentation of what was returned to Patient #2.
During an interview after 1:00 p.m. Staff #2 and #15 confirmed they could not tell how much of the patients medications were sent home with them.


Review of the clinical record of Patient #3 revealed she was a 55 year old female who was admitted on 05/12/2015 with a diagnosis of Major depression disorder.
Review of facility medication administration records revealed Patient #3 was receiving the cholesterol agent Simvastatin 20 milligrams by mouth at bedtime while in the hospital.
Review of discharge medications dated 05/15/2015 listed the following:
Zocor 20 milligrams tab at bedtime by mouth.
Simvastatin 20 milligrams once daily by mouth.
Both orders were listed on the discharge instructions.
According to the discharge instructions there was documentation of Zocor and Simvastatin being home medications and no prescription was provided at discharge.
There were not clear instructions on how Patient #3 was to take her cholesterol medication.
During an interview on 07/21/2015 after 1:00 p.m., Staff #15 confirmed the medications as written were a mistake. The computer system merged both the Simivastin written at admission and the Zocor written at discharge on the discharge instructions. The physician failed to remove one of the medications off before finalizing his discharge orders.

Review of a policy named "Patient's Home Medications" dated 02/2012 revealed the following:
Unless administration of a patient's personal drugs is authorized by the responsible prescribing physician, these drugs shall be sent home with the family or others. If the drugs must be retained in the facility, they shall be sent to the pharmacy where they will be packaged, sealed and labeled with the patient' name (exception: Psychiatric units and rehab shall store them in a locked cabinet in the medication room).Upon discharge, the stored drugs shall be returned to the patient.
Review of a policy named "Handling of Illicit Substances" dated 09/2012 revealed the following:
A. Definitions
1. Substances generally defined as illicit:
a. All medications and drugs prescribed, controlled, and over-the -counter and
b. Alcohol containing substances and alcoholic beverages.
2. When possible, all prescriptions medications that are secured will be given to family members to take home.
3. When this is not possible, and /or when unidentified substances are secured, such substances will be sent to the Hospital pharmacy for appropriate identification, storage and/or disposition.
a. The Registered Nurse will place secured substance(s) in a pharmacy envelope that has the patient's identifying label placed on it.
b. The envelope will be signed, dated, sealed and the pharmacy or house supervisor will be called to deliver it to the Hospital pharmacy during hours of operation. Until secured by the pharmacy, the envelope will be stored on the unit in a locked enclosure or box in a secure area (e.g. a lock box in the medication room).
5. All prescription medications will be returned to the patient at the time of discharge per physician order.

Review of a policy dated 01/2012 named "Nursing Discharge" revealed the following:
PURPOSE:
Provide information and reduce anxiety when discharging patient from hospital, rehabilitation or psychiatric program.
POLICY:
5. Discharge summary shall include, but not limited to:
b. medications and medication instructions (to include home medications)

Based on observation, interview and record review the facility failed to ensure non-nacotic medications and narcotics were reconciled and tracked in a manner to prevent diversion. They failed to ensure pharmacy supervision was provided on these medications on 1 of 1 unit (Psych unit).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:

During an interview on 07/21/2015 after 12:15 p.m., Staff #8 reported they take patients home medications, inventory them, and locked them in the medication room. Observation of the storage area revealed the medications were being kept in a locked cabinet in the medication room. Staff #8 reported the medications are counted on admission and then again on discharge. The medication count should be logged on the form and witnessed by 2 people.
During an interview on 07/21/2015 after 1:50 p.m. Staff #8 reported the narcotics were treated the same way. The pharmacist was not being called to come and inventory or secure the medications. The narcotics were counted on admission and then again on discharge.
During an interview on 07/21/2015 after 2:40 p.m., Staff #9 (pharmacist) confirmed the medications were to be sent home with family or kept in the pharmacy until discharge. Staff #9 reported they were not monitoring the narcotics or other medications that were being kept in lock up on the unit.
There was no system in place to ensure medications were not diverted.

Review of the clinical record of Patient #1 revealed he was a 25 year old male admitted to the observation unit on 06/27/2015 with suicidal and homicidal thoughts.
According to a "Home Medication Inventory" dated 06/27/2015, Patient #1 had 26 tablets of Latuda (psychotropic agent) with him at admission. The medication was received from Patient #1 to be locked up.
According to the record Patient #1 was admitted into the adult psych unit on 06/29/2015. Patient #1 was discharged from the facility on 07/03/2015.
According to a "Home Medication Inventory" two nurses signed off as witnesses on 07/03/2015 for returning medication to Patient #1. There was no documentation of the medication being counted or documentation of the amount of medication returned to Patient #1.


Review of the clinical record of Patient #2 revealed he was a 54 year old male admitted on 05/09/2015 with chief complaints of suicidal and homicidal ideations.
According to a "Home Medication Inventory" dated 05/09/2015, Patient #2 had the following medications with him on admission:
*APAP/Codeine (the narcotic agent Tylenol with Codeine) 168 tablets;
*Orajel - one tube of the pain agent;
*Timolol Maleate - one bottle of eye drops used for glaucoma.
The medication was received from Patient #2 to be locked up.
According to the record Patient #2 was admitted into the adult psych unit on 05/11/2015. Patient #2 was discharged from the facility on (7 days later) 05/18/2015.
According to a "Home Medication Inventory" there was no documentation of the medication being counted on discharge or documentation of what was returned to Patient #2.
During an interview after 1:00 p.m. Staff #2 and #15 confirmed they could not tell how much of the patients medications were sent home with them.
Review of the clinical record of Patient #3 revealed she was a 55 year old female who was admitted on 05/12/2015 with a diagnosis of Major depression disorder.
Review of facility medication administration records revealed Patient #3 was receiving the cholesterol agent Simvastatin 20 milligrams by mouth at bedtime while in the hospital.
Review of discharge medications dated 05/15/2015 listed the following:
Zocor 20 milligrams tab at bedtime by mouth.
Simvastatin 20 milligrams once daily by mouth.
Both orders were listed on the discharge instructions.
According to the discharge instructions there was documentation of Zocor and Simvastatin being home medications and no prescription was provided at discharge.
There were not clear instructions on how Patient #3 was to take her cholesterol medication.
During an interview on 07/21/2015 after 1:00 p.m., Staff #15 confirmed the medications as written were a mistake. The computer system merged both the Simivastin written at admission and the Zocor written at discharge on the discharge instructions. The physician failed to remove one of the medications off before finalizing his discharge orders.

Review of a policy named "Patient's Home Medications" dated 02/2012 revealed the following:
Unless administration of a patient's personal drugs is authorized by the responsible prescribing physician, these drugs shall be sent home with the family or others. If the drugs must be retained in the facility, they shall be sent to the pharmacy where they will be packaged, sealed and labeled with the patient' name (exception: Psychiatric units and rehab shall store them in a locked cabinet in the medication room).Upon discharge, the stored drugs shall be returned to the patient.
Review of a policy named "Handling of Illicit Substances" dated 09/2012 revealed the following:
A. Definitions
1. Substances generally defined an illicit:
a. All medications and drugs prescribed, controlled, and over-the -counter and
b. Alcohol containing substances and alcoholic beverages.
2. When possible, all prescriptions medications that are secured will be given to family members to take home.
3. When this is not possible, and /or when unidentified substances are secured, such substances will be sent to the Hospital pharmacy for appropriate identification, storage and/or disposition.
a. The Registered Nurse will place secured substance(s) in a pharmacy envelope that has the patient's identifying label placed on it.
b. The envelope will be signed, dated, sealed and the pharmacy or house supervisor will be called to deliver it to the Hospital pharmacy during hours of operation. Until secured by the pharmacy, the envelope will be stored on the unit in a locked enclosure or box in a secure area (e.g. a lock box in the medication room).
5. All prescription medications will be returned to the patient at the time of discharge per physician order.
The policies were contradicted each other.

Based on interview and record review the facility failed to ensure:

A. emergency personnel designated as being on the trauma team were available to provide emergency services at all times.
B. there was efficient coordination between trauma team members and the ED (emergency department) personnel.
C. documentation of monitoring on a physician who's scheduling of elective surgeries caused conflicts with the trauma team availability.
Refer to tag A1103 for additional information.

Based on interview and record review the facility failed to ensure:
A. emergency personnel designated as being on the trauma team were available to provide emergency services at all times.
B. there was efficient coordination between trauma team members and the ED (emergency department) personnel.
C. documentation of monitoring on a physician who's scheduling of elective surgeries caused conflicts with the trauma team availability.
This deficient practice was found in 1 of 1 ED and had the likelihood to cause harm to all patients presenting to the emergency department (ED).
Findings include:

Review of the clinical record on Patient #8 revealed he was a 34 year old male who presented to the ED on 04/05/2015 (Sunday) with a gunshot wound (GSW) to the abdomen.
According to the chart the switchboard was notified and a trauma alert page was made at 6:55 p.m. CPR (cardio-pulmonary resuscitation) was started on Patient #8 enroute to the facility and Patient #8 was in asystole (without cardiac activity) on arrival to the hospital at 6:57 p.m. CPR continued in the ED. Surgeon #20 performed a thoracotomy (surgical cut to open the chest wall up) to clamp the aorta (largest artery in the body) in the ED. After 45 minutes of CPR the code was called off.
According to the record, Patient #8's time of death was 7:40 p.m.
Review of form named "TRAUMA TEAM ALERT/ACTIVITION and RESPONSE TIMES" dated 04/05/2015 revealed sections for staff on the trauma team to sign in and time on arrival to the ED. Surgical nurses, anesthesia, and the surgical tech was signed and timed in at 7:00 p.m. Lab did not sign in and two of the physicians and the house supervisor signed the sheet, but failed to time in.
Review of a facility investigation and resolution plan revealed two occurrence reports were received on 04/05/2015 involving Physician #22 behavior. Physician #22 was performing elective surgeries after hours and on weekends. On 04/05/2015 he scheduled an elective surgery, the surgery call crew showed up at the hospital at 3:00 p.m., and eventually left at 4:40 p.m. because the physician had not showed up at the hospital. Physician #22 showed up at 6:00 p.m. and the call crew had to come back in.
According to the report on 04/09/2015, a meeting was held with the operating room (OR) nurses involving events that occurred on Sunday (04/05/2015). A review was performed on the case of the GSW in the ED (Patient #8) that was unable to go to the OR due to call crew in an elective case.
On 04/17/2015 additional complaints came in about Physician #22 intentionally delaying cases in order to keep operating room crew there after hours. The facility met with Physician #22 on 04/22/2015 and he was placed on a corrective action plan.
During interviews on 07/22/2015 after 9:15 a.m., the following was reported about emergency services involving the trauma team:
Staff #1 reported because of the 04/05/2015 and other complaints Physician #22 was placed on terms. Staff #1 reported the surgeon would not have taken Patient #8 to the operating room because he was already coding. Because of the potential of needing to go to surgery, that prompted them to no longer do elective cases on the weekend. Staff #1 reported the back-up plan was to call additional staff in when the trauma team staff were in an (emergent) surgery on the weekend. Staff #1 reported spots checks were done on Physician #22 to make sure he was complying, but she had no documentation of that.
Staff #16 confirmed the problems they had with Physician #22 and the incident that occurred on 04/05/2015. Staff #1 confirmed the plan was for no elective surgeries to be performed on the weekend. They would only do emergent cases on inpatients only. Staff #16 confirmed there was no backup plan for his operating room staff that was scheduled for an emergent surgical case and the trauma team at the same time. Staff #16 reported he guesses himself or another nurse would have to be the back-up. Staff #16 reported there was only 8 nurses working in surgery and if he had to put them on call like that they would lose nurses. Staff #16 reported he was monitoring Physician #22 surgery scheduling, but was not keeping documentation of compliance.
Staff #17 confirmed she was scheduled to be on the trauma team on 04/05/2015, but was in an elective surgery. Staff #17 reported while they were in surgery, the house supervisor came back to the surgery area a couple of times asking for supplies for the ED. Staff #17 confirmed there was no back-up plan if they were tied up with urgent surgeries and were also scheduled for the trauma team. Staff #17 confirmed she signed the other surgery staff names on the trauma code form and put the times of 7:00 p.m. on the sheet. Staff #17 confirmed the surgical case did not end until 7:10 p.m. and the patient went to recovery at 7:12 p.m. Staff #17 confirmed they were not in the ED at the documented time.
Staff #18 confirmed she was scheduled to be on the trauma team on 04/05/2015, but was in an elective surgery. Staff #18 confirmed her name was written on the code sheet, but she never went to the ED because she was recovering a patient. Staff #18 confirmed she did not know a trauma patient was in the ED because she did not hear a page for a Code 88. Staff #18 reported the backup plan for when she was scheduled for an emergent case and the trauma team at the same time was as follows; to finish her patient in recovery as soon as possible and then go the ED or call her charge nurse.
Staff #19 (Chief nursing officer) and Staff #3 (Chief executive officer) reported the backup plan for the trauma team replacement would be to call staff who were not on the first trauma team in. They both reported there was no documentation on Physician #22 to show he was complying with the scheduling problem.
Staff #2 (Quality) reported the backup plan would be to stabilize the patient and transfer them out.

The facility failed to ensure staff had clear knowledge of the back up plan in the event the operating room staff was on a case and scheduled for the trauma team at the same time. There was no documented monitoring of the Physician #22 who scheduled a weekend elective case during the timeframe the operating room staff was scheduled for the trauma team on-call duty on 04/05/2015.


Review of a policy named "Trauma Team Protocol" approved 01/2014 revealed the following:
Purpose:
To provide an efficient, coordinated approach to caring for the severely injured trauma patient.
1. ACTIVATION OF TRAUMA ALERT PROTOCOL:
The Trauma Alert protocol should be activated (trauma team mobilized) upon notification from pre-hospital provides that a CRITICAL trauma patient is in route to the trauma center.
2. PRIOR TO ARRIVAL-(PREPARATION)
Trauma team members should assume the following responsibilities:
4. TRAUMA TEAM MEMBERS RESPONSIBILITIES:
a. Emergency Department Physician
i. Assumes responsibility for injured patient until Surgeon arrives. Perform assessments, procedures and diagnostic studies as necessary.
l.Operating Room Personnel
The surgery department is jointly committed as various other departments within the facility to provide safe and appropriate care for those patients requiring prompt surgical intervention as a result of trauma.
i.Surgical Notification:
1. The surgery department should be notified by appropriate Emergency Department personnel during normal hours of operation of a potential trauma case requiring surgical intervention by the paging system.
2. The Surgery Charge Nurse or designated person should advise the OR personnel and begin preparing for the potential case.
3. The surgeon should notify the surgery department to verify the need for special equipment and availability of room.
4. The RN circulator should notify the Surgery Charge Nurse of need for additional personnel during afterhours procedures.
iv.Staff Availability
1. The surgery department should maintain appropriate staffing during normal operation to handle the requirements of trauma.
2. Surgery department staff are on-call after hours and for weekend/holiday coverage. The call crew should respond within 30 minutes of notification.
3. The need for additional personnel should be at the discretion of the RN circulator who is responsible for contacting the Surgery Charge Nurse as soon as possible.