HospitalInspections.org

Based on observation, record review and interview the facilities pharmaceutical services failed to:

A. Ensure nursing staff were educated on pharmacy policy and procedure titled "Patients Own Medications-(Inpatient Home Medications Brought to The Hospital)."

B. Implement a process to ensure staff were notified a patient's home medications are secured with security personnel and ensure home medications are returned to the patient/ designated caregiver upon discharge.

Policy and Procedure titled "Patients Own Medications (Inpatient medications brought to the hospital), Policy # RX623, effective date 10/2016, date revised 02/2023. Purpose: To establish a procedure for identification, storage, dispensing, and administration of patients "own" medication. Policy: Use of patients own medication is generally discouraged. When a patients own medication cannot be returned home or with a caregiver they must be secured and stored for safekeeping in Security ...When approved by the patients physician, a patient's own non-controlled medication, including patient's own sample medications, may be used by the patient while in the hospital. This only applies to the inpatient setting. III Procedures: 1. Sending Patient's Own Medications Home ...If a patient has brought his/her own personal medication to the hospital, if appropriate the nurse returns the medication home with an authorized family member or designated caregiver. 2. Storage of patients Own medications from home ...If the medications cant be sent home or is a sample that is demmed medically necessary by a physician. The nurse secures the medications, completes a Medication Storage Register (see Appendix A), places them in a sealed opague envelope, and sends to Security for storage ( See Appendix B). 1. If patient is conscious or an authorized family is present but not able to take the medication home: a. Nurse is to place the medication in an opague envelope while in the presence of the patient and/or authorized family member. It is then sealed and the Patients Own Medication Inventory form is signed by BOTH the nurse and the patient or the authorized family member. d. Prior to patient being discharged from the hospital: i. the patients nurse contacts Security to retrieve the patients own medications from storage ...ii. The patients own medication is then returned by the nurse to the patient or patients authorized family member and signed for by patient or patients authorized family member and nurse returns the Medication Inventory form to Security ...iii.Document in Meditech that the patients medication were sent home and with whom they were sent home.

Findings included:

During an observation on 02/27/2024 it was noted Patient #1's medication was located in the security department. Fifty-five days after patient #1 was discharged.

Record review of The Medication Inventory Form on 01/03/2024 listed the medication name, dosage, and quantity of pills. The form was signed by Patient #1, Personnel #10 and Personnel #12.

Record review of nursing orientation packet for Personnel #9 and #10 did not include education on the facilities policy and procedure for "Patients Home Medications Brought to the Hospital."

In an interview with Personnel #6 on 02/27/2024 at 10:45 AM stated the facility policy is as follows ...if a patient brings their home medications to the hospital and the medication is not a controlled substance or the patient is not being administered the medication, our process is to complete The Medication Inventory Form which is a 2-part form, the medication is sealed in a bag and taken to security. The original form is kept with the medication and the copy is placed on the patient's chart. The copy of the Medication Inventory Form that is placed on the chart would notify the nurse the patients home medications are being secured in our security department. The pharmacy department does not inspect or follow up with medications currently stored with security personnel. Our security department does not currently notify patients of unclaimed medications."

In an interview with Personnel #10 on 02/29/2024 at 4:45PM stated she was not aware of the process for securing medications. The policy "Patients Own Medications (Inpatients Home Medication Brought to the Hospital ) is a new policy effective January of 2024. She stated she had not received education or training on this policy. Personnel #10 stated she was not aware the copy of the Medication Inventory Form that is placed on the chart is the process for notifying the nurse that a patient's home medications are being secured with security personnel.

In an interview with Personnel #9 on 02/28/2024 at 12:30 AM, stated she was not aware the copy of the Medication Inventory Form that is placed on the chart is the process for notifying the nurse that a patient's home medications have been secured by security. Personnel #9 stated there is not a process notifying staff that patients medications are being held with security.

In an interview with Personnel #1 on 02/28/2024 at 12:00 PM confirmed the nursing orientation packet for agency personnel does not include education on the facilities policy and procedure for Patients Home Medications brought to the hospital.

In an interview with Personnel #2 on 02/29/2024 at 5:00 PM confirmed there was a failure in the facilities process for educating the nursing staff of new pharmacy policies and procedures, ensuring staff are aware of patients whose home medications are being safely secured in the security department and a process to ensure patients are returned their home medications upon discharge. Personnel #2 confirmed staff had not been educated on the new policy and procedure. Personnel #2 confirmed all the above findings.