HospitalInspections.org

Based on interview and record review, the facility failed to ensure the Director of Pharmacy is an active member of the Pharmacy and Therapeutics committee. The facility census was three.

Findings included:

1. Review of the Medical Staff Meeting minutes from January 2013 through September 2013 showed that this group met once a month. Pharmacy and Therapeutics is a regular agenda item of this meeting with a notation that this subcommittee will report in January, April, July, and October. Committee meeting minutes showed the last report on Pharmacy and Therapeutics was April 17, 2013. All other meeting minutes for 2013 indicated no representation by Pharmacy.

The Pharmacy and Therapeutics section of this meeting should be utilized to establish and review the facility's medication formulary (list of medicines available at the hospital), establish and review policies for pharmacy and other areas of care, such as Medical Nutrition Therapy, therefore it is important that a Pharmacist actively participate in the committee.

2. During an interview on 10/23/13 at 12:30 PM Staff C, CEO, stated that there has not been a permanent Director of Pharmacy employed by the hospital since July 31, 2013. She stated that the facility had an interim Director of Pharmacy until August 31, 2013 but he was not able to continue because of his commitments elsewhere. She further stated that pharmacists were brought in from the systems other pharmacies occasionally, as needed, during September and October and that another interim Director of Pharmacy started on October 23, 2013. She stated that a new permanent Director of Pharmacy has been hired, he will start around December 1, 2013 and he will be expected to attend the Pharmacy and Therapeutic Committee meetings.

3. During an interview on 10/23/13 at 12:50 PM, Staff J, Director of Quality, stated that there was a Medical Staff Meeting on October 16, 2013 but Pharmacy was not represented at that meeting. Staff J stated that Pharmacy is always invited to the meeting but not typically represented.

Based on interview and record review the facility failed to provide safe oversight of medication being dispensed and repackaged. This failure occurred when systems were not in place to track medication that were dispensed from the pharmacy prior to review by a pharmacist and medication being repackaged was not being tracked. This failure had the potential to affect all hospital patients that received medication. The facility census was three.
Findings included:
1. Review of the facility's policy titled, "Drug Distribution & Administration" dated 04/18/13, showed direction to facility staff that only a registered pharmacist licensed in the state of Missouri, or an authorized pharmacy personnel under the direction of a pharmacist, shall dispense medication, make label changes or transfer medications to a different container.
2. During an interview on 10/22/13 at 10:00 AM Staff A, Pharmacy Technician, stated that she does dispense medication from pharmacy stock for orders or cart stock without pharmacist review because there is not a pharmacist on staff or always available. Staff A stated that a record of medication dispensed without oversight by a pharmacist is not tracked.
During an interview on 10/22/13 at 10:15 AM Staff A stated that medication is repackaged from bulk bottles into unit dose containers (one pill/tablet per container). Staff A stated that there is not a mechanism to track the medications that have been repackaged or to verify that the process has been reviewed by a pharmacist.
3. During an interview on 10/22/13 at 3:15 PM Staff C, Chief Executive Officer, (CEO), stated that she understood why medication dispensed from the pharmacy without pharmacist oversight or any tracking mechanism is a potential problem.
4. During an interview on 10/23/13 at 9:20 AM Staff B, Director of Nursing DON, stated that the pharmacy technician pulls the medication to fill the patient medication drawers and to fill the nursing and Emergency Department stock drawers based on the orders and needs. If a pharmacist is not there to check, it's not a problem because the nurses check the medication before it's given.
5. During an interview on 10/23/13 at 11:25 AM Staff D, Interim Director of Pharmacy (started today 10/23/13), stated that a log of medications that are repackaged should be kept.
6. During an interview on 10/23/13 at 11:45 AM Staff C, CEO stated that the facility does not have a policy on repackaging medication or keep a log of medications that have been repackaged.