HospitalInspections.org

Based on interview and record review the hospital failed to ensure informed consent was obtained for urine drug screens for 2 of 10 sampled patients. (patients #2 and #4)

The findings include:

A review of patient #2's clinical record revealed he presented to the central receiving area of the hospital on 1/29/22. The record revealed a urine drug screen was obtained. The record did not contain any documentation that the hospital had obtained the patient's consent for the drug screen prior to conducting the testing.

On 02/23/2022 at approximately 2:00 PM, the Risk Manager (RM) was interviewed during record review of patient #2. She confirmed the record did not have a consent for the drug screen, the practice for obtaining consent and the right of patients to decline the urine drug test.

A review of patient #4's clinical record revealed she presented to the central receiving area of the hospital on 2/9/22. The record revealed a urine drug screen was obtained. The record did not contain any documentation that the hospital had obtained the patient's consent for the drug screen prior to conducting the testing.

A review of the hospital's policy and procedure for Inpatient Voluntary Admission effective February 2021, revealed nursing staff will complete a pre-admission nursing screen including obtaining consent for a urine drug screen.

On 2/22/22 at approximately 9:15 AM, the Assistant Director of Clinical Services was interviewed and he confirmed the practice for obtaining consent and the right of patients to decline the urine drug screen.

Based on interview and record review the hospital failed to ensure, a Registered Nurse (RN) completed a nursing patient assessment on admission for 1 of 10 sampled patients. (patient #9)

The findings include:

Patient #9's clinical record was reviewed and revealed he presented to the hospital's central receiving area and was evaluated for admission on 2/2/22. The record reflected a Licensed Practical Nurse (LPN) performed an admission nursing assessment. There was no documentation that an RN reviewed the assessment or conducted an assessment.

On 2/22/22 at approximately 10:00 AM, an interview with the Assistant Clinical Director Services was conducted and he confirmed the assessment policy and procedure. He confirmed no RN reviewed the LPN's assessment for patient #9.

A review of the hospital's policy, Nursing Assessment Process effective May 2021, revealed "The nursing assessment must be completed by the RN for inpatient admission. If the assessment is completed by an LPN, it must be reviewed and signed off by an RN."

Based on observations, interview and policy review the facility failed to maintain admitted patients home medications, to include narcotics in a secure manner, for 2 of 2 observations.

The findings include:

On 2/21/22 at approximately 2:00 PM, an observation was made in the medication room between the adult and the children's inpatient units. The medication room door was locked, accessible by badge access. A metal narcotic box was observed on the wall, unlocked, with 2 keys on a keychain in the 2 locks of the lockbox. Observed 3 brown envelopes in the lockbox.

On 2/21/22 at approximately 2:10 PM, an interview was conducted with the Director of Nurses, (DON), who confirmed the box should be locked and the keys should not be in the box. The DON confirmed patient home medication which includes narcotics and non-narcotics are stored in the lockbox.

On 2/22/22 at approximately 9:10 AM, a second observation was made of the lockbox. Two keys were observed in the two locks of the lockbox. Observed an envelope with a form on top with Hydrocodone 5/325, a narcotic, with 11 tablets and Vimpat, an anticonvulsant considered a narcotic, with 16 tablets.

On 2/22/22 at approximately 9:10 AM, an interview was conducted with Staff A, a Licensed Professional Nurse, (LPN) who confirmed the cabinet held patient medications to include narcotics. Staff A, LPN confirmed the keys should not be in the medication cabinet, but should be kept in the top drawer of the medication cart.

A review of the policy titled, "Medication and Storage", last revised in February 2017 revealed medication keys are to be carried only by the on-duty nursing staff at all times and all controlled substances will be contained under double lock in the medication room and counted daily at the end of each shift.