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COOKEVILLE REGIONAL MEDICAL CENTER 1 MEDICAL CENTER BOULEVARD COOKEVILLE, TN 38501 Oct. 22, 2013
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on medical record review, review of employee records, review of facility policy, review of facility documentation, and interview, the facility failed to notify Quality Management of medications of discharged residents being removed from the facility; failed to implement measures to prevent a recurrence of the medications of discharged patients being removed from the facility; and failed to document the removal of medications from the facility as a medication variance for two (#2, #6) of six patients reviewed.

The findings included:

Patient #2 was admitted to the facility on on [DATE], with diagnoses including Gastrointestinal Bleed, [DIAGNOSES REDACTED], Anemia, Abdominal [DIAGNOSES REDACTED]tosis, Urinary Tract Infection, and Bilateral Lower Extremity Deep Vein Thrombosis.

Review of the discharge summary dated May 30, 2013, revealed the patient was placed on palliative measures for the rest of the hospitalization and was discharged on [DATE], with comfort measures.

Medical record review of physician's orders dated May 21, 2013, revealed the patient was receiving Labetalol (blood pressure) 50 mg three times daily; Trazodone (depression) 100 mg at bedtime; and Neurontin (neurological pain) 300 mg twice daily. Continued medical record review revealed the Neurontin was discontinued on discharge.

Medical record review of the Medication Administration Records (MAR) revealed Licensed Practical Nurse (LPN) #1 documented the Neurontin, Labetalol, and Trazodone were administered to the patient at 8:39 p.m., on May 27, 2013, and at 5:36 a.m., on May 28, 2013. Continued review of the MAR revealed the Trazodone was held at 8:39 p.m., on May 27, 2013, because the patient was drowsy.

Resident #6 was admitted to the facility on on [DATE], with complaints of Chronic Back Pain related to Lumbar compression Fracture at L3 with intractable back and leg pain.

Medical record review of laboratory reports dated June 27, 2013, revealed the patient's Prothrombin time (PT) (clotting time of blood) was 21.9 (normal 12.1 - 14.8).

Medical record review of physician's orders dated June 29, 2013, revealed an order for Phytonadione (Mephyton) (reverse action of blood thinners) 5 mg twice daily.

Medical record review of the MAR revealed LPN #1 documented Phytonadione was administered to the patient on June 29, 2013, at 9:30 p.m. and June 30, 2013, at 7:58 p.m.

Employee record review revealed employee #1 was hired on November 21, 2011 and transferred to 4E, the neruological unit, on November 11, 2012. Further review of the employee record revealed the employee signed an acknowledgement the facility was a drug-free workplace and the employee had received training on abuse prevention.

Review of the employee's record revealed a disciplinary action dated September 17, 2013, with the violation being job performance/policy violation. Continued review of the disciplinary action revealed "...On September 10, 2013, the facility became aware the employee received a traffic violation...on August 22, 2013. As a result of this violation a search of the employee's vehicle was conducted. This search conducted by (named officer) revealed two medication bags. One bag contained two medications which had been prescribed for a patient whose identification label was present on the tag. This patient had been on 4E and was discharged on [DATE]. One bag contained one medication which had been prescribed for a different patient and the identification was on the tag. This patient was discharged on [DATE]. An audit of the charts of these patients confirmed these medications were prescribed and this employee had been assigned to them. Employee had documented...administered/held the medications. Employee violated the facility's confidentiality policy by taking personal inventory out of the facility. Employee fraudulently documented...had given the medications. Due to the nature of these policy violations employee is terminated. Policy violations of this nature can compromise patient care due to patient not receiving prescribed med (medication). Employee has breached trust by stealing medications and fraudulently documenting that...gave the medications..."

Review of the facility policy entitled Medications, PC-145, revealed "...Discontinued and outdated drugs and containers with worn, illegible, or missing labels, shall be returned to the pharmacy for proper disposition..."

Review of medication variances between May 1, 2013 to September 30, 2013, revealed no documentation the medications were removed from the facility.

Interview with the Risk Manager and the Vice President of Quality on October 22, 2013, at 1:10 p.m., in the Vice President's office, confirmed they were unaware of the situation until October 22, 2013. Continued interview with the Risk Manager confirmed there was no data on the medication variance report concerning the incident since they were unaware of its occurrence.

Review of facility documentation and interviews with the Risk Manager on October 22, 2013, at 12:30 p.m., in the Risk Management Office, and by telephone on October 23, 2013, at 10:30 a.m., confirmed the Quality/Risk Management department was not notified of the incident so it could be investigated and included in the monthly Quality Management report; the removal of medications of discharged patients was not reported as a medication variance; and, there was no implementation of a plan to educate staff on the issue and prevent this type of incident from recurring in the future.