The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

PEAK VIEW BEHAVIORAL HEALTH 7353 SISTERS GROVE COLORADO SPRINGS, CO March 21, 2013
VIOLATION: DELIVERY OF DRUGS Tag No: A0500
Based on review of medical records and staff interviews, the pharmacist failed to ensure that the medications ordered were administered as ordered, including the correct time of administration for sample patient #2.. The failure created the potential for negative patient outcome.

Findings:

1. The hospital pharmacist failed to ensure that the automated medication dispensing system and the newly activated electronic medical record system accurately documented administration of home medications on the Medication Administration Record MAR) for sample patient #2.

a. Review of the medical record for sample patient #2 during the survey revealed that ordered home medications for including, magnesium, Vitamin B-12 and CoQ-10 were not recorded in the electronic MAR report as having been given.

b. During a telephone interview with the Director of Nursing on 03/22/13, s/he confirmed that the medications were not recorded as having been given according to the electronic MAR report provided in the medical record. S/he reviewed nursing notes that indicated that all medications had been administered for some of the doses in question, but the notes did not specify which medications were given, The electronic MAR either did not contain a complete an accurate report of the medications administered, because they were home medications that were not pulled from the electronic medication dispensing machine (which automatically records each dose in the MAR), or the medications were not given. S/he stated that s/he would immediately be working to correct the problem with a combination of staff training, changes to the electronic medical record and use of the medication dispensing machine to accommodate home medications.

2. The hospital pharmacist failed to ensure that a system was in place to monitor all medications to ensure that they were administered as ordered, including the correct time of administration.

a. Review of the medical record for sample patient #2 during the survey revealed that an order was written on 02/09/13 for the patient to receive amitriptilyne 20 mg at 5:30 p.m.. Review of the electronic MAR report revealed that the patient was actually administered that medication at 7:46 p.m. on that date.

b. During a telephone interview with the Director of Nursing on 03/22/13, s/he confirmed that the medication the medication was administered late according to the electronic MAR report provided in the medical record. S/he stated that would be considered a medication error because it was given more that 2 hours later than ordered.