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Based on interview and record review, the hospital failed to ensure drugs and biologicals were controlled and distributed by acceptable standards of practice as evidenced by the pharmacist failing to review all first dose medications for appropriateness, duplication, interactions, allergies, sensitivities or other contraindications before the dose was dispensed and administered to patients.

Findings:

Review of the hospital's policy titled, "Access to Medication When the Pharmacy is Closed", policy number 5.09, provided by S1ADM (Administrator) revealed in part the following: ....Medications are only obtained prior to a pharmacist's review, when the clinical condition of the patient warrants immediate administration of that medication....When the pharmacy is closed, medication orders are reviewed by a health care professional determined to be qualified by the hospital....A pharmacist is readily available, either on-call or at another location, to provide medication information or provide medications that are not accessible to non-pharmacy staff. A pharmacist conducts a retrospective review of all medication orders as soon as a pharmacist is available or the pharmacy opens....

In an interview on 10/15/14 at 11:10 a.m., S3Director of Risk Management/PI (Performance Improvement) stated the hospital contracted the pharmacy services and stated the Pharmacy was open from 6:30 a.m./7:00 a.m. to 3:00 p.m. S3Director of Risk Management/PI stated after hours the hospital uses a "Night Locker" of medications and the "PINC" (Pharmacy Intervention Nursing Compliance) system to check for contraindications of the medication when a new medication is ordered after the pharmacy is closed. S3Director of Risk Management/PI explained the "PINC" system was a computer software system developed by the consulting pharmacy. She explained the nurse enters the patient's name into the system and the system pulls up the patient's medication profile. She stated the nurse then enters the new medication and the "PINC" system alerts if there are any contraindications. S3Director of Risk Management/PI stated if the "PINC" system identified any contraindications, the nurse was to contact the patient's physician. S3Director of Risk Management/PI stated the Pharmacist does not review the patient's medications until the next day when the pharmacy is open. S1ADM (Administrator) who was also present for the interview stated the staff does not start all medications at night, and stated they only give the patients what they need at night and what the physician orders.

In an interview on 10/16/14 at 10:05 a.m., S4RPH stated he was the Director of Pharmacy. S4RPH verified the hospital used the "PINC" system to review new medications ordered after the pharmacy closed at 3:00 p.m. S4RPH stated he reviews new medication orders when he comes in the following day at 6:00 a.m. S4RPH stated, "It's the first thing we do." S4RPH verified this review was after the patient had received the first dose of the new medication. S4RPH further stated he was on-call 24 hours a day and was called 3 times last night. S4RPH stated he did not have a way to review patient medications at home and stated the staff would have to verbally report the patient's medications. S4RPH stated one of the calls he received last night was a nurse who was not sure about contraindications. S4RPH stated he did not do a review of the patient's medications and he instructed the nurse to contact the physician. A log of the medication usage from the "Night Locker" was requested for review.

Review of the Pharmacy Night Cabinet Log from 10/01/14 to 10/15/14 revealed 25 routinely ordered new medications were removed from the "Night Locker." for 23 different patients.

Review of the medical record for Patient #4 revealed the patient was admitted to the hospital on 10/13/14 at 10:57 a.m. with a diagnosis of PTSD (Post Traumatic Stress Disorder). Review of the physician's orders dated/timed 10/13/14 at 9:10 p.m. revealed a verbal order as follows: Unit Restriction. Haldol 5 mg. Benadryl 25 mg. by mouth every 6 hours as needed for agitation. Haldol 5 mg./Benadryl 25 mg. Intramuscular injection (IM) every 6 hours as needed for psychotic agitation. If psychotic agitation continues after Haldol 5mg./Benadryl 25 mg. injection is given, add Ativan 2 mg. IM every 6 hours as needed for psychotic agitation. Review of the MAR (Medication Administration Record) dated 10/13/14 revealed the patient received the oral dose of Haldol/Benadryl at 9:10 p.m. and the IM dose of Haldol/Benadryl at 9:20 p.m. There was no documented evidence that the medications were removed from the "Night Locker" (not on Pharmacy Night Cabinet Log) and there was no evidence the pharmacist reviewed the medication orders prior to the first dose.

In an interview on 10/16/14 at 2:20 p.m., S3Director of Risk Management/PI provided the following information on the "PINC" system for review: "Using the "PINC" program to review medication orders during times when the pharmacy is closed. Your facility has provided you with a new tool to help with the review and documentation process of medications that are being removed from the pharmacy night cabinet during times when the pharmacy is closed. This software program allows approved personnel access to review the patient pharmacy profile and "post" newly prescribed medications against existing profiled medications to determine whether there are drug/drug, food/drug, or patient allergy. If a problem is found the operator will be prompted on screen that the software system found a problem and will automatically print out a drug/drug, food/drug, or allergy monograph....Nursing Administration will determine which individuals will have access to the "PINC" program...." S3Director of Risk Management/PI stated the program required 2 nurses to access and stated one of the nurses was the Supervisor.