HospitalInspections.org

Based on document review and interview, the hospital failed to follow its policy titled "Pharmacy- Patient's Own Medication Storage and Destruction Policy" in 1 (patient #1, #2, and #3) of 3 patient medical records reviewed.

A medical record review of Patient #1 was conducted on 6/25/25 after 1:00 PM. During the document review, it was noted that Patient #1was complaining of a headache. Patient #1 stated that the pain in his head was related to his blood pressure. Patient #1 explained to Staff RN #13 that it had been hurting since he woke up this morning and that his blood pressure medication alleviates the headache. Patient #1 stated that his daughter had his blood pressure medication and asked if he could take one of his pills. Staff #13 called and got a verbal order from Physician #18 to give the patient his home blood pressure medication. Staff #13 gave Patient #1 his home medication around 6:15 AM on 4/29/25.

An interview with Staff #13 was conducted on 6/25/25 after 1:00 PM. Staff #13 was asked if she had the Pharmacist come down and verify that the medication she was giving Patient #1 was the correct medication. Staff #13 stated that she did not verify the medication with the Pharmacist. Staff #13 agreed that she did not follow the facilities policy titled "Pharmacy- Patient's Own Medication Storage and Destruction Policy".

A document review was conducted with Staff #1 on 6/25/2025 after 1:00 PM. The document was the hospital policy titled "Pharmacy- Patient's Own Medication Storage and Destruction Policy," effective date 10/2003 and reviewed on 01/2024. The policy states:

"Policy:
Medications that have been brought in by patients at admission will be sent home with the family. If not, the medications will be stored in the Pharmacy Department in a specific location and according to a specific procedure.
Procedure:
Drugs that are not to be used during the patient's stay at the hospital will be given to the patient's family to take home.
In the event that the medications cannot be sent home, the medications are sent to the Pharmacy department along with a copy of the "Patient's Personal Medications" sheet provided by the pharmacy. This sheet provides the patient's name and an itemized list of the medications. The sheet indicates the patient's name, room number, patient ID number, physician, who identified the medication as well as the signature of the nurse forwarding the bag to the pharmacy and the patient's signature ..."

An interview was conducted with staff #1 on 6/25/2025 after 1:00 PM. Staff #1 was asked if the hospital followed their policy titled "Pharmacy- Patient's Own Medication Storage and Destruction Policy". Staff #1 confirmed that they did not follow their policy.