HospitalInspections.org

Based on policy and procedure review, "Basic Rules" review, consent review, medical record review, and staff interviews nursing staff failed to follow up on a positive urine drug screen for 1 of 10 medical records reviewed (Patient #1).

The findings include:

Review on 09/20/2017 of a policy titled "Search Policy and Procedure" last updated 04/2017 revealed "...Breathalyzer and Urine Quick-tox will be administered...on a random and /or for cause basis..."

Review on 09/21/2017 of "Basic Rules" revealed "...staff reserves the right to conduct random alcohol and drug screenings..."

Review on 09/21/2017 of "Consent for Treatment and Conditions of Admission" revealed "...Any such use of alcohol, prescribed and/or illicit contraband found in the possession of the patient will be removed and/or destroyed; patient will be discharged and/or prosecuted..."

Review of the closed medical record on 09/20/2017 of Patient #1 revealed a 23 year old female admitted on 06/05/2017 to the detoxification unit for severe opioid use disorder. Review revealed Patient #1 signed the "Basic Rules" and "Consent for Treatment and Conditions of Admission" on 06/05/2017 at 2304. Review revealed on 06/13/2017 Patient #1 was transferred to the partial level hospitalization service. Review revealed on 06/18/2017 Patient #1 was ordered to start a new medication once a urine drug screen had been done. Review revealed on 06/18/2017 Patient #1's urine drug screen was negative and she was started on the new medication. Review revealed on 06/24/2017 a urine drug screen was done and indicated no use of prohibited substances. Review revealed an additional drug screen was done on 06/25/2017 at 2215 and was positive for marijuana. Review failed to reveal why the 06/25/2017 drug screen was done for Patient #1 and if any follow up was done by nursing or clinical counselors about the positive drug screen. Review revealed Patient #1 continued treatment in the partial hospitalization level of care service and was discharged on 07/06/2017.

The charge nurse on the night of 06/25/2017 was not available for interview during the survey.

Interview on 09/20/2017 at 1625 with Counselor #2 revealed random urine drug screens are done daily and patients were selected randomly by their record number.

Interview on 09/20/2017 at 0855 with Administrative Staff (AS) #1 revealed random urine drug screens were done during daytime hours. Review of the positive urine drug screen of Patient #1 with AS #1 revealed that because the urine drug screen was done at 2215 it would mean that it was a "for cause" drug screen. Further interview revealed AS #1 could not find in the medical record and did not recall why the 06/25/2017 drug screen had been done for Patient #1. Interview revealed AS #1 could not find in the medical record any follow-up regarding the positive result. Interview revealed the expected process for a positive drug screen was the staff that did the drug screen would notify the charge nurse of the results. Once notified of positive results by the staff the charge nurse would notify either the director of nursing (DON) or AS #1. The patient would then be transferred, administratively discharged, or placed on a contract for change. Interview revealed this was not done for Patient #1.

Interview on 09/20/2017 at1500 with Counselor #1 revealed he did not recall Patient #1 having a positive urine drug screen or being accused of selling or having illicit drugs. Interview revealed Patient #1 finished the full program and encouraged her peers.

Interview on 09/20/2017 at 1600 with the director of nursing (DON) revealed the certified nursing assistant who did the urine drug screen did not recall Patient #1 but if the urine drug screen was done at 2215 it would have been done for cause. Interview revealed the DON could not find in the medical record the reason why a drug screen was done on Patient #1 or what follow-up had been done after a positive drug screen.

NC00129849