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OCEANS BEHAVIORAL HOSPITAL OF PERMIAN BASIN 3300 S FM 1788 MIDLAND, TX 79706 July 23, 2019
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on a review of the clinical record and an interview with staff, the facility failed to maintain medical records that were accurately written, promptly completed, properly filed and retained, and accessible.

Findings were:

Review of the clinical record for patient #1 revealed that she was admitted to OBH on 4-9-19 on a voluntary basis with primary diagnoses of bipolar disorder and generalized anxiety disorder. Patient #1 had a history of thyroid disease and had had a hysterectomy in 2014. She stated allergies to latex, nubain and stadol.

A document in the clinical record of patient #1 titled "Home Medication List" indicated that patient #1 brought the following medications with her at the time of her admission.
* Vitamin D2 (quantity of 3)
* Indomethacin (quantity of 20)
* Buspar (quantity of
* 47)
* Vyvanse (quantity of 5)
* Zolpidem (quantity of 17)
* Armour Thyroid (quantity of 13)
* Estradiol (quantity of 24)
* Nicotine Polacrilex (quantity of 8)
* Acetaminophen (quantity of 19)
* Bismuth Subsalicylate (quantity of 10)
The admission nurse and a witness nurse signed that they received the medications and witnessed the count of the controlled substances. The box on the form was checked to indicate that the medications were secured in the medication room but the box on the form was not checked to indicate that the narcotics were secured in narcotic storage and a count sheet was started, as instructed on the form. Two of the listed medications were narcotics. Vyvanse is classified as a CII controlled substance and Zolpidem (Ambien) is classified as a CIV controlled substance. The area of the form to be used at the time of discharge was not completed, as it was neither signed by the discharging nurse nor the witness nurse as to the presence of narcotics. The clinical record contained no indication that a count sheet for narcotics had been completed or maintained throughout the patient's stay and in an additional interview with staff #2 (nursing director), staff #2 confirmed that no such sheet was found in the clinical record or the pharmacy.

A document in the clinical record of patient #1 titled "Physician Order/Admission Medication Reconciliation" listed the medications patient #1 was taking at the time of admission. The listed included "Armour Thyroid 30 mg PO", which was to be taken daily. A check mark indicated that the medication should be continued. The document contained signatures to indicate that the nurse had read back and verified the orders with the physician over the telephone. Review of the medication administration record for patient #1 revealed the following documentation in regards to the Armour Thyroid:
* 4-10-19 - Medication not listed on MAR
* 4-11-19 - Hand-written entry states "Armour Thyroid PO daily" but no dosage, route or time is indicated. No initials were present to indicate that medication was given.
* 4-12-19 - Medication not listed on MAR.
* 4-13-19 - Medication listed on MAR but nurse's initials are circled to indicate that the medication was not given.
* 4-14-19 - Medication listed on MAR but nurse's initials are circled to indicate that the medication was not given.
* 4-15-19 - Medication listed on MAR but nurse's initials are circled to indicate that the medication was not given.
* 4-16-19 - No MAR for this date was found in the clinical record.
* 4-17-19 - Medication listed on MAR and initialed by nurse.
* 4-18-19 - Medication listed on MAR but initialed with "NA", which were not the initials of the medication nurse on 4-18-19.
The clinical record contained no documentation or explanation as to why the Armour Thyroid was not given on the days indicated on the MAR.

Documentation provided by staff #5 (facility's contract pharmacist) indicated that a staff physician assistant had given staff #5 a telephone order on 4-11-19 at 1:32 that stated "Hold armour thyroid while [patient #1 is] inpatient. Levothyroxine 50 mcg po daily." A review of the MAR revealed that the Levothyroxine order had printed out for 4-12-19 and that the medication had been given. The order was not present on the MAR for any other days of patient #1's stay. The physician order section of the clinical record contained no order for the Levothyroxine.

A review of the physician's orders in the clinical record for patient #1 revealed the following orders:
* 4-9-19 at 8:36 pm - "Ativan 1 mg PO x 1 dose now for anxiety".
The MAR contained no documentation that the medication had been given.
* 4-10-19 at 8:55 pm - "Zofran 4 mg PO q 6 hrs PRN for nausea & vomiting".
Although ordered by the physician on 4-10-19, the medication order was not added to the MAR until 4-18-19.

A review of the MAR in the clinical record for patient #1 revealed the following PRN medication given:
* 4-18-19 at 12:12 am - Acetaminophen 650 mg po
The clinical record contained no documentation as to the effectiveness of the medication.

Facility policy MM-01 titled "Medications" states, in part:
"Physician/Licensed Independent Practitioner (LIP) writes medication order clearly and legibly on the Physician Order Sheet in the patient record.
...
Documentation
All medication shall be documented on the patient's Medication Administration Record (MAR) immediately after administration.
RN/LVN/LPN
...
2. If a dose of scheduled medication is withheld or not given, circles the hour of administration for the medication dose in question and initials next to circled time. Records a full explanation in the integrated progress notes of physician/LIP notification. (Medication variance must be completed and placed in bin to be processed).
...
7. Documents on PRN MAR effectiveness of any new medication prescribed by physician."

Facility policy MM-04 titled "Home Medications" states, in part:
"Purpose:
To establish protocol for the inpatient program regarding the regulation of medications brought into the facility from a patient's home.
Policy:
All medications brought into the facility by persons in the inpatient program (or their family members/significant others) will be immediately surrendered to the nursing staff for the purpose of safeguarding during treatment, and communicating to admitting physician any medication patient may have been taking prior to admission.
...
Admit RN
1. Documents on the Multidisciplinary progress note and Home Medication List form those medications brought in by the patient. Whenever possible, send all medications home with family members.
...
3. Completes home medication form. If home medications are controlled substances, the number of controlled pills are counted and witnessed with(sic) along with a 2nd witnessed licensed nurse. Both nurses document the count, date/time, and sign the form.
4. If the home medication is a controlled substance, two nurses count and document same and begin a count log. Controlled Medications are stored in the locked medication cart or designated cabinet. The key to the designed(sic) cart or cabinet is stored in Med Dispense.
...
discharged Patients:
1. An order will be obtained at the time of discharge to instruct nursing whether the home medications are to be returned to the patient or discarded.
2. Nursing will document on the Home Medication List Form the medications returned or discarded.
3. Nursing disposes of any home medications not claimed by the patient at the time of discharge in accordance with State and Federal regulations."

Facility policy MM-14 titled "Reconciled Medications" states, in part:
"Purpose:
Medication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner, or level of care.
...
Upon Admission:
1. The nurse completing the admission assessment will obtain and document the patient's current medications.
...
4. Physicians shall review the current medications with the admitting nurse and reconciles the medications that are to be continued and provides orders for the medications to the nurse. The physician/LIP will make any additions, deletions or corrections to the patient's medication orders using the physician's order sheet.
5. The nurse documents the order on the order form and indicates the medications have been reconciled with the physician/LIP.
6. The physician/LIP authenticates the orders.
7. Orders are sent to the pharmacist for dispensing of the medications. The pharmacist reviews the mediations(sic) for contraindications and communicates any indications to the nurse and physician/LIP."

The above was confirmed in an interview with the CEO and other administrative staff on the afternoon of 7-23-19.