HospitalInspections.org

Based on observations, interviews, and record reviews, the hospital failed to ensure the patient's own medications brought into the hospital was monitored and a Practitioner responsible for the patient had issued an order consistent with the hospital policy pertaining to self- administration of medications in that:

Medications brought in from home, were found on patient's bedside table.

This failure placed the patients at an increased of risk of potential harm from adverse drug events that can potentially impact the patient outcome and subsequent health care utilization.


Findings included:

During the tour of the hospital care unit on the morning of 10/03/19 the surveyor observed medications kept on the patient # 1 bedside table. The medications were:

One tube of Ipratropium Bromide 0.03% nasal solutions
A bottle containing Cranberry 4200 mg tablets
These findings were confirmed by staff member #2

Interview with Patient # 1 on 10/03/19 at 11:15 a.m. revealed she was self-administering the above medications. She reported she brought the medications from home.

Interview with staff member # 4 on 10/03/19 at 11:20 a.m. revealed the medications were not in the medication record and there was no physician order. The surveyor asked staff member #4 if there was a physician's order for this patient to have home medications at the bedside. Staff member # 4 checked the electronic medical record and confirmed that there were no such an orders. Additionally, staff member #4 checked the electronic medical record and informed the surveyor that the patient was not on any of these medications.

Observation of patient #3 room on 10/03/19 at 11:35 a.m. revealed the following medications on the patient's bedside table:

A blister pack of Bekunis 3mg/5mg containing 15 tablets
A blister pack of Peptiva containing 11 capsules.

These findings were confirmed by staff member #2.

Interview with patient # 3 on 10/03/19 at 11:45 a.m. revealed he had been taking the mentioned medications during his stay at the hospital.
Interview with Staff member #5 revealed she was not aware the patient was taking the mentioned medications. She reported there was no physician order for self-administration of the medications and the medications had not been prescribed by his practitioner. Staff member # 5 also informed the surveyor that the medications that were found in the patient's room should not be at the bedside.

Review of hospital policy # 150, titled: " Self- administration of medications" with a last revised date of 11/08/2018 stated: "1 ...may self-administer medications only if there is a specific physician order in the medical record stating that the patient/caregiver may do so. 5.Medications may not be left unsecured at the bedside."