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Based on staff interview, medical record and Policy and Procedure review, the hospital failed to ensure Physician's telephone orders had been dated and/or timed for two (2) out of 31 Patient's reviewed; Patients 10 and 31.

This failure had the potential for patient harm related to unauthenticated Physician's telephone orders for medications and/or care/treatment.

Findings:

Review of Patient 10's medical record revealed three (3) Physician's telephone orders that had not been dated and/or timed. Patient 31's medical record revealed nine (9) Physician's telephone orders that had not been dated and/or timed.

Review of the hospital's Rules and Regulations indicated: "5.4 Members Orders: 5.4.1 ...A verbal order or telephone order shall be considered to be written if accepted by a registered nurse or licensed pharmacist and signed and dated. Physician's making verbal or telephone orders shall countersign such orders within 24 hours for medication orders ...".

In an interview with the Director of Nursing services (DON) on 4/25/17 at 3:10 p.m., the DON acknowledged the Physician's telephone orders for Patient 10 and 31 did not have documented evidence of a date and/or time signed by the physician. The DON stated the Physician should have signed, dated and timed the telephone orders within 24 hours.

Based on staff interview, medical record and Policy and Procedure review, the hospital failed to ensure three (3) consents for psychotropic medication had been authenticated after a verbal consent had been obtained for one (1) out of 31 Patient's reviewed; Patient 9.

This failure had the potential for misinformation concerning psychotropic medication use and side effects which was given to Patient 9's parent/guardian.

Findings:

Review of the medical record revealed Patient 9 was a minor child. Two (2) verbal consents dated 4/12/17 and one (1) verbal consent dated 4/13/17 for three different psychotropic medications had a notation in the "Parent (Guardian) Signature" box which read: "V/C [verbal consent] from mother". There was no documented evidence Patient 9's mother had authenticated the consents for psychotropic medications.

Review of the hospital's Policy and Procedure titled, "Informed Consent Psychotropic Medication", undated, indicated: "Policy: It is the policy of [name of hospital] to initiate treatment of patient's medication for psychotropic medications only after such a person has been informed of his/her right to accept or refuse such medications and has consented to administration of such medications as defined by the [name of State]. The Pharmacy Department must have evidence of a signed consent prior to dispensing any psychotropic medication".

Review of the hospital's Policy and Procedure titled, "Consents, Informed" dated 3/06, indicated:
1. "Policy: ...Written consent is mandatory for ...Psychotropic Medications";

2. "Procedure: ...For minors, verbal consent will be obtained from the legal guardian/parent by the medication nurse, and documented on the medication consent form. Parents will be requested to sign the medication consent form when arriving on the unit for visiting hours".

In an interview with the Director of Nurses (DON) on 4/25/17 at 3 p.m. the DON acknowledged the three consents for psychotropic medication should have been authenticated by Patient 9's parent.

Based on observation, staff interviews, and document review, the facility failed to ensure appropriate disposal of medications to a census of 95 when a Licensed Psychiatric Tech (LPT 1) did not dispose of medications including controlled substances according to professional pharmacy principles, and hospital Policy and Procedures.


This deficient practice had the potential for improper disposal of medications and/or diversion of controlled substances.


Findings:

During a concurrent drug storage inspection and interview on 4/24/17, at 10 a.m., with LPT 1, he stated that in the event that a prescribed medication in pill form was dropped on the floor, refused, or expired, he would crush the medication and dispose of it in the sink of the medication room. LPT 1 added, in the event of a prescribed injectable narcotic like Ativan (a medication used to treat anxiety and produce a calming effect) that was drawn in a syringe, but was not used because it was refused or dropped, he would dispose of the medication in the sharps container. The Director of Nursing (DON) was present when the LPT gave his responses. The DON acknowledged LPT 1 did not follow the policy for disposal of medications.

Review of hospital policy and procedure, titled, "Disposal of Unused Drugs and Sharps," indicated the following: "...Controlled substances- Schedules 2, 3, 4, and 5 (Food and Drug Administration classification of drugs into groups based on risk of abuse or harm)...Controlled substances must be sent to a medication waste disposal company for destruction and the following must be recorded in the log: with patient's name, name and strength of drug, prescription number and name of pharmacy filling prescription, amount sent, date sent. Non-controlled substances shall be sent to a medication waste company for destruction..."

Based on observation, staff interview and Policy and Procedure review, the hospital failed to ensure medication was secured when the medication room door in Adult 1 Unit was observed to be open and unlocked. There were no personnel noted inside the unlocked open medication room.

This deficiency had the potential for unauthorized staff, patient's or visitor access to medication.

Finding:

In a concurrent observation of the Adult 1 Unit medication room and interview with the Maintenance Engineer (ME) on 4/24/17 at 9:30 a.m., the ME acknowledged and confirmed the medication room door had been left open and unlocked, with no staff inside the medication room.

Review of the hospital's Policy and Procedure titled, "Medication Security" undated, indicated:
1. "Policy: All drugs stored in [name of hospital] shall be accessible only to authorized personnel";

2. "Procedure: All drugs shall be stored in locked containers or areas ...All medication at nursing stations shall be in lockable storage at all times. ...When unattended, the medication carts and medication rooms are to be locked."

In an interview with the Adult 1 Unit Manager (A1 UM) on 4/24/17 at 9:40 a.m., the A1 UM acknowledged the medication room should have been locked.

Based on observation, staff interview and Policy and Procedure review, the hospital failed to ensure Ativan (a narcotic medication) was securely stored when the narcotic medication refrigerators were found unlocked on Adult 1 Unit, Adult 2 Unit, and the Adolescent/Pediatric Unit.

These failures had the potential for unauthorized access to narcotic medications and possible drug diversion.

Findings:

In a concurrent observation of the Adult 1 Unit. Adult 2 Unit and the Adolescent/Pediatrics Unit narcotic medication refrigerators and interviews with the Unit Managers (UM's) for those specific units on 4/24/17 between 9:30 to 11:30 a.m., the UM's acknowledged and confirmed the narcotic medication refrigerators were unlocked and were supposed to be locked at all times and behind a locked medication room door.

Review of the hospital's Policy and Procedure titled, "Medication Security", undated, indicated:
1. "Policy: ...Controlled drugs will be double locked at all times".

Based on observation, staff interview and Policy and Procedure review, the facility failed to ensure expired and improperly stored medications were available for use when:

1. A Lantus (insulin) pen was refrigerated when it was supposed to be kept at room temperature; and when

2. Valproic Acid (a mood stabilization medication) 16 ounce bottle, 250 milligrams (mg)/5 milliliters (ml) was opened 12/30/15, had expired 12/30/16, and was available for patient use.

These failures had the potential for decreased efficacy of the medication to be administered.

Findings:

1. An observation of Adult 2 Unit medication refrigerator on 4/24/17 at 10 a.m., revealed a Lantus insulin pen that had been opened, used, and re-refrigerated. Pharmacy instructions on the box indicated, "This product, after opening for use, store at room temperature".

In an interview with the Pharmacy Director (PD) on 4/24/17 at 11 a.m., the PD confirmed the Lantus insulin pen should not have been refrigerated after it had been opened and used. The PD confirmed the insulin should have been stored at room temperature.

2. An observation of the medication room on the Adolescent/Pediatric Unit on 4/24/17 at 10:47 a.m., revealed a 16 ounce bottle of valproic acid that had expired 12/30/16.

In a concurrent observation of the expired valproic acid medication and interview with the PD on 4/24/17 at 11 a.m., the PD acknowledged the valproic acid should have been discarded after 12/30/16 and confirmed the medication should not have been available for patient use.

Review of the hospital's Policy and Procedure titled, "Outdated or otherwise unusable drugs", undated, indicated: "Procedure: Outdated or otherwise unusable drugs shall be returned to the pharmacy. These drugs will be placed in the pharmacy box in each medication room for the pharmacist to pick up".

Review of the hospital's Policy and Procedure titled, "Refrigerated Drug Storage", undated, indicated: "All refrigerated drug storage areas will be inspected daily to ensure compliance with drug storage standard."

Based on observation, staff interview, and Policy and Procedure review, the hospital failed to ensure the accuracy of medications stored in the night locker (a secure locked area containing pharmacy and therapeutics approved drug products) when the number of Seroquel (an antipsychotic medication) tablets in the night locker exceeded the number listed in the medication log.


This deficient practice had the potential for inaccurate documentation and diversion of medications.

Findings:


During an inspection of the night locker, on 4/25/17, at 1 p.m., with Nurse Manager (NM) of unit Adult 1, there were 10 tablets of Seroquel XR 50 mg found. The list of medications stored in the night locker indicated there should be 5 (Seroquel XR 50 mg) tablets. This was acknowledged by the NM.

In an interview with the Pharmacy Director (PD) on 4/25/17, between 2-3 p.m., the PD stated, "The quantity of each medication in the night locker should match the quantity on the list of the medications in the night locker.

Based on observation and interview, the hospital failed to provide a environment that ensured safety and well-being of patients for a census of 95 when the gardener provided access to a locked area of the hospital to three non-hospital staff who were unknown to him.

This deficient practice had the potential to jeopardize patient safety.

Findings:

During the first attempt to formally enter the hospital, on 4/24/17, at 8:30 a.m., there was no response to several doorbell rings at the locked front door of the hospital. A second attempt to enter the hospital, using a telephone located outside of the locked iron gate on the left side of the hospital was made and there was no response to several phone rings.

On 4/24/17, at 8:40 a.m., a middle-aged looking individual walked near the iron gate and surveyors asked him if he worked at the hospital, his response was, "garden". This gentleman did not appear to speak English. He opened the locked gate without identifying who we were and why we needed access to the hospital.