HospitalInspections.org

Based on interview, record review, and policy review it was determined the facility failed to ensure medication was dispensed consistent with the facility's policy. The facility dispensed Dental Cotton Balls (cotton balls saturated in Lidocaine-Tetracaine medication used to relieve toothache/pain) to Patient #1's caregiver, but failed to label the medication in accordance with the facility's policy that included the instructions for use of the medication.

The findings include:

Review of a facility policy titled, "Labeling Standards," revealed prescriptions intended for use outside the hospital would be labeled to ensure complete understanding and compliance by the patient/family. The policy stated the minimum requirements for labeling included: Patient name, Physician name, Date the prescription was filled, Serial file number for the prescription, Generic drug name, Amount of drug in dosage, Direction for use, Quantity in the container, and Expiration date.

Medical record review revealed Patient #1 presented to the facility's Emergency Department (ED) by private vehicle on 05/13/18 at approximately 4:24 PM. Patient #1's caregiver from an Adult Day Health program had transported Patient #1 to the ED because the patient had severe dental pain that resulted in a seizure. According to the medical record, Patient #1 was treated and released with instructions to follow up with the patient's family dentist.

An interview with Patient #1's legal guardian on 06/12/18 at 7:00 PM revealed the patient lived in a Group Home (Supports for Community Living) and attended an Adult Day Health program on weekdays. The patient's guardian stated the hospital notified the guardian of the patient's ED visit on 05/13/18, and told the guardian that medications would be sent to the Group Home to administer until the resident could see a dentist.

An interview with a caregiver on 05/16/18 at 1:59 PM revealed Patient #1 was treated by the ED physician on 05/13/18, and the ED sent unlabeled medicated Dental Cotton Balls home with the patient. However, the Group Home and the Adult Day Health facility were not permitted to administer the Dental Cotton Balls for pain relief because there was not an appropriate label affixed to the medication.

Interview with Registered Nurse (RN) #1 on 06/12/18 at 2:10 PM revealed the RN was assigned to provide care for Patient #1 on 05/13/18, when the patient was treated at the ED. RN #1 stated the physician prescribed Dental Cotton Balls for dental pain and she sent them home with Patient #1. However, RN #1 stated she did not label the cup used to store the Dental Cotton Balls for home use.

Interview with Physician #1 who provided care for Patient #1 on 05/13/18 revealed he did not recall telling staff to send the Dental Cotton Balls home with Patient #1; however, it was facility protocol to ensure medications were labeled prior to sending them home with a patient.

An interview was conducted on 06/12/18 at 4:30 PM with the Facility Pharmacist who stated it was facility policy to label all medications sent home with patients. According to the Facility Pharmacist, blank labels were available and should have been completed and placed on the Dental Ball Container sent home with Patient #1.