HospitalInspections.org

Based on medical record review, interviews and review of policy and procedure, medication ordered by the Physician, was not administered to Patient Identifier (PI) Numbers (#) 1 and 2 by the Registered Nurse assigned to the patients. This deficient practice affected two of ten sampled medical records and had the potential to affect all patients served.

Findings Include:

1). A review of the medical record revealed PI # 1 was admitted to the Psychiatric Unit on 12/29/14 at 15:41 with diagnoses to include Cognitive Disorder, Rule out Dementia and Rule out Major Depression.

Tremors in PI # 1's hands was documented in the Nursing Assessment dated 12/29/14 at 14:50.

The Current/Home Medication Reconciliation/Discharge Form, dated 12/29/14 at 1552, and signed by the physician, revealed an order for Primidone 50 mg. (milligrams) 2 tabs (tablets) po (by mouth) bedtime.

A review of PI # 1's Medication Administration Record (MAR), Administration Period: 12/29/14 07:00 to 12/30/14 06:59, revealed Primidone (Mysoline) 50 mg./ 100 mg / 2 tab (tablet) po (by mouth) was scheduled to be given at 22:00 on 12/29/14. (Mysoline is a medication that can be used to treat essential tremor, www.WebMD.com).

There is no signature in the area on the MAR on 12/29/14 at 22:00 to indicate Mysoline was given to PI # 1 by a nurse. A capital letter F with a circle around the letter and "50 mg. (milligrams) not available," was documented in the signature area. According to the legend on the MAR, a code F indicates "Other- see notes."

A review of the Interdisciplinary Progress Notes dated 12/29/14 at 19:45
revealed no documentation/ rationale by the RN (Registered Nurse) to explain why the Mysoline was not given to PI # 1 as ordered by the physician.

During an interview on 2/4/15 at 10:16, the Pharmacist (Employee Identifier # 2) verified Mysoline was not given to PI # 1 on 12/29/14 at 2200. The Pharmacist said, "I know the medication (Primidone / Mysoline) was not in the Accudose system..."


2). PI # 2 was admitted to the Unit on 1/8/15 with a diagnosis of Schizoaffective Disorder.

The Current/Home Medication Reconciliation/Discharge Form, dated 1/9/15 (time not documented), and signed by the physician, revealed an order for Timolol .5% eye drops 1 gtt (drop) each eye q (every) hs ( hour of sleep).

A review of PI # 2's Medication Administration Record (MAR) revealed Timolol .5 eye drops 1 drop each eye hs (bedtime) was scheduled to be given at 22:00 on 1/9/15. (Timolol is a medication that works to decrease fluid production and pressure inside the eye. www.drugs.com.).

There is no signature in the area on the MAR at 22:00 on 1/9/15 to indicate Timolol drops were given to PI # 2 by a nurse. "Not available," was documented in the signature area on the MAR.

During a telephone interview on 2/5/15 at 10:14 AM, the Interim Nurse Manager (EI # 1) stated she spoke with the pharmacist about PI # 2's eye drops. "He (pharmacist) can't tell if the eye drops arrived" (on the unit) for PI # 2 on 1/9/15.


Policy and Procedure Review:

A review of Medication Guidelines (Patient Care Policy and Procedure Manual), Review Date: 9/11 revealed:

i. Purpose of this policy is to ensure that medications are safely and accurately prepared, dispensed, ordered, transcribed and administered and medication errors are avoided.

ii. This policy applies to any health care worker who is authorized to prepare, dispense order, transcribe and/or administer medication.

iii. Rationale: "...For a medication regimen to be most effective, medications must be administered properly."

...K. Pyxis (now Accudose) Medstation is an automated dispensing and documentation system for controlled and non-controlled medications.

VI. Procedure:
A. Medication orders
1. Medication orders are written on physician order forms...
3. Medication orders are...transmitted via scanner to the Pharmacy.
4. Medication orders are reviewed for appropriateness by a pharmacist and entered into a medication profile. The computerized Medication Administration Record (MAR) is generated form this patient profile.
5. Once review is completed, the medication is made available for nursing to administer...


Interviews

During a telephone interview on 2/5/15 at 10:14 AM, the Interim Nurse Manager (EI # 1) stated the after hours process to obtain patient medications if the medication is not available in the Accudose system on the Psychiatric Unit is as follows:
- Physician order scanned to the pharmacy at main hospital campus
- Order (medication) filled by pharmacist at main hospital campus
- Medication transported by security personnel from main hospital campus to the Psychiatric Unit
- Security personnel "hopefully" gives medication to a nurse

As a result of this deficient practice, PI # 1 and PI # 2 failed to receive medication ordered by the physician.

Based on interviews, medical record review and review of policy and procedure, the pharmacist failed to ensure medications sent from the Hospital's Main Campus to the Psychiatric Unit are documented upon arrival of the medication at the Psychiatric Unit. This deficient practice affected Patient Identifier # 1 and # 2 (patient medication was not available and not administered as ordered by the physician). The deficient practice has the potential to affect all patients on the Psychiatric Unit who require medication from the pharmacy at the Hospital's Main Campus when the medication is not available in the Accudose System (Psychiatric Unit) and the Psychiatric Unit's Pharmacy is closed.

Findings Include:

1). A review of the medical record revealed Patient Identifier (PI) # 1 was admitted to Hospital A on 12/29/14 at 15:41 with diagnoses to include Cognitive Disorder, Rule out Dementia and Rule out Major Depression.

The Current/Home Medication Reconciliation/Discharge Form, dated 12/29/14 at 1552, and signed by the physician, revealed an order for Primidone 50 mg. (milligrams) 2 tabs (tablets) po (by mouth) bedtime.

A review of PI # 1's Medication Administration Record (MAR) revealed Primidone (Mysoline) 50 mg./ 100 mg / 2 tab (tablet) po (by mouth) was scheduled to be given at 22:00 on 12/29/14.

There was no signature documented in the area on the MAR on 12/29/14 at 22:00 (10:00 PM) to indicate the Primidone/Mysoline was given to PI # 1 by a nurse.

During an interview on 2/4/15 at 10:16 AM, the Pharmacist (Employee Identifier # 2) was asked to describe how medications ordered by a physician, but not maintained in the Accudose system on the Unit, get to the unit when the Psychiatric Unit's Pharmacy is closed. According to the Pharmacist, a nurse scans the medication orders to the Pharmacy on the Main Hospital Campus. The Pharmacist (Main Campus) reviews and prepares the medication. The medication is brought from the Main Campus to the Psychiatric Unit by security staff. The Pharmacist verified Mysoline was not given to PI # 1 on 12/29/14 at 2200. The Pharmacist said, "I know the medication (Primidone) was not in the Accudose system..."

The Pharmacist (EI # 2) also stated there is no documentation regarding the medication: no-one signs for the medicine and there is no way to track if the medication arrived at the Psychiatric Unit when medication is transported from the Pharmacy on the Main Campus to the Psychiatric Unit. The Pharmacy on the Psychiatric Unit closes at 1600 Monday through Friday and is closed on weekends.

2). PI # 2 was admitted on 1/8/15 with a diagnosis of Schizoaffective Disorder.

The Current/Home Medication Reconciliation/Discharge Form, dated 1/9/15 (time not documented), and signed by the physician, revealed an order for
Timolol .5% eye drops 1 gtt (drop) each eye q (every) hs ( hour of sleep).

A review of PI # 2's Medication Administration Record (MAR), Administration Period: 1/9/15 07:00 to 1/10/15 06:59, revealed Timolol .5 eye drops 1 drop each eye hs (bedtime) was scheduled to be given at 22:00 on 1/9/15. Timolol is beta-blocker and works to decrease fluid production and pressure inside the eye, www.drugs.com.

There was no signature documented on the MAR at 22:00 on 1/9/15 to indicate Timolol drops were given to PI # 2 by a nurse. "Not available," was documented in the signature area.

During a telephone interview on 2/5/15 at 10:14 AM, the Interim Nurse Manager (EI # 1) stated she spoke with the pharmacist about PI # 2's eye drops. "He (pharmacist) can't tell if the eye drops arrived" (on the Psychiatric Unit from the Main Campus) for PI # 2 on 1/9/15.


Policy and Procedure Review:

A review of Medication Guidelines (Patient Care Policy and Procedure Manual), Review Date: 9/11 revealed:

i. Purpose of this policy is to ensure that medications are safely and accurately prepared, dispensed...and administered and medication errors are avoided.

ii. This policy applies to any health care worker who is authorized to prepare, dispense order, transcribe and/or administer medication.

iii. Rationale: "...For a medication regimen to be most effective, medications must be administered properly."


Interviews

During a telephone interview on 2/5/15 at 10:14 AM, the Interim Nurse Manager (EI # 1) stated the after hours process to obtain patient medications if the medication is not available in the Accudose system on the Psychiatric Unit is as follows:
- Physician order scanned to the pharmacy on Main Campus
- Order (medication) filled by pharmacist on Main Campus
- Medication transported by security personnel from Main Campus to the Psychiatric Unit
- Security personnel "hopefully" gives medication to a nurse at the Psychiatric Unit.

There is no documentation or verification the medication is transported and/or received at the Psychiatric Unit from the Main Campus.

As a result of this deficient practice, PI # 1 and PI # 2 did not receive medication as ordered by the physician. There is no documentation to verify medications sent from the Pharmacy on the Main Campus arrives at the Psychiatric Unit, are given to licensed nursing staff and/or placed in a secure area on the Unit.