HospitalInspections.org
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STRONG MEMORIAL HOSPITAL
ADMINISTRATION OF DRUGS
Tag No.: A0405
Based on document review and staff interview the nursing staff did not comply with facility policy related to the procurement of controlled substances. Failure to comply with facility policy could potentially place patients at risk.
Findings include:
Interview with Staff (A), (C) and (E) on 2/6/17 revealed that during the night shift on 12/19/16, staff from the surgical intensive care unit (SICU) provided Dilaudid to a nurse who presented to the SICU requesting the medication for a patient on another unit.
Review of Policy and Procedure titled "Medication Administration, Controlled Substances" revised 10/28/14 revealed the following: "Pharmacy personnel are responsible for replenishing all medication inventories based upon PAR (periodic automatic replenishment) levels established by usage. Emergency controlled substances service is available at all times. The borrowing of controlled substances between units is prohibited."