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Based on a review of the South Dakota Department of Health complaint intake information, record review, interview, and policy review, the provider failed to ensure an investigation had been conducted for one of one sampled patient (1) who had been "violated" by one of one patient care technician (PCT) Y. Findings include:

This failure has the potential to cause harm to other patients since no investigation had been conducted.

Notice:
On 7/6/23 at 2:45 p.m. the facility chief executive officer O was informed of an Immediate Jeopardy (IJ) for failure to conduct an investigation to ensure that this was an isolated incident.

Plan:
The facility provided the following acceptable removal plan on 7/12/23 at 1:30 p.m. for patient rights:
1. "Human resources has started an investigation as of Thursday 7.6.23 at 4:30 p.m. patient care technician was suspended from work until the investigation was completed."
2. "Further investigation was done by human resources between 7.7.23 and 7.10.23, interviews with patient care technician, unit supervisors, registered nurse assigned to the patient, and the resource nurse."
3. "As of 7.10.23 at 3:00 p.m. human resource's investigation is complete. Human resources concluded this was an isolated incident and the employee was cleared to return to work. Appropriate education was provided to the patient care technician by both the resource nurse and the registered nurse caring for the patient, announcing himself upon entering the room and ask the patient permission prior to providing personal cares."
4. Education was created, 7.10.23:
a. "Review of the policy for adult protective service reporting."
b. "Patient perception."
c. "Staff expectation."
d. "Incident reporting process."
e. "Who to contact if a situation occurs."
5. Education has been rolled out 7.11.23 at 1:00 p.m.:
a. "Education reviewed with supervisors for the brain and spine unit 7.11.23 at 1:00 p.m."
b. "Education reviewed with all leads, including nurse leaders, pharmacy leaders, supervisors, and nurse educators for all units 7.12.23 at 9:00 a.m."
c. "Education will then be created online for all employees to review and sign by 7.12.23 Completion of education will be required and reviewed by leaders of every area."
1. "Leaders from the nursing units will monitor, verify, and require that all staff is educated prior to their shift."
2. "Prn staff will be contacted and mandated to complete education prior to their next shift."
d. "Quality will receive a copy of the signed education, as well as the Healthstream tracker to verify education is completed by all staff through unit leaders daily starting 7.11.23 A report will then be given to the CNO daily."
6. "Medical support services plan to also provide immediate jeopardy items to the quality committee."
a. "Quality committee will then review and give further approval of action plan."
b. "Follow up will be reported out to the quality committee with the roll-up to the board of trustees."

The removal plan for the IJ was received and accepted on 7/12/23 at 1:30 p.m. On 7/13/23 at 11:00 a.m. the implementation of their plan was verified and their IJ status was removed while the surveyors were onsite.

Findings include:

Review of the South Dakota Department of Health complaint intake information revealed:
*Patient 1 had been diagnosed with cerebral palsy and had a spinal cord injury which required the use of a wheelchair for mobility.
*Patient 1 had been sleeping and PCT Y began performing his catheter care.
*PCT Y had been asked multiple times by patient 1 to stop with his cares once he woke up.
*PCT Y finally stopped and exited the room.
*Patient 1 reported to registered nurse (RN) S that PCT Y had touched him inappropriately and PCT Y was not allowed to care for him anymore.
*PCT Y had been reassigned to another patient care area on that floor.
*Patient 1 had been sexually abused in the past by a male and would have preferred female staff whenever possible to perform cares.
*Patient 1 had thought about leaving the hospital against medical advice (AMA) because he had not felt safe.

Review of patient 1's electronic medical record (EMR) revealed:
*He had been admitted on 6/3/23 with a diagnosis of failure to thrive.
*On 6/28/23 at 10:28 p.m. licensed practical nurse (LPN) V had noticed that patient 1 had been gone from the unit for several hours.
*On 6/28/23 at 10:30 p.m. RN U noticed that patient 1's belonging had been removed from his room.
-She contacted security and they reviewed the video cameras.
-Patient 1 had been seen on the camera with his service dog, belongings, and a female visitor leaving AMA from the hospital on 6/28/23 at 5:11 p.m.

Interview on 7/5/23 at 2:15 p.m. with RN Q and RN W regarding training provided to PCTs revealed:
*Hospital wide training for new employees had been conducted by human resources.
-Hospital wide training included patient rights and abuse/neglect among other areas.
-PCT Y had been hired in April 2023.
*PCTs would have received more on the job training on their designated unit.
-On the unit training would have been completed differently with PCTs that had more experience.
*PCTs were expected to have reported any suspected abuse or neglect to the nurse.
*The nurse would have reported any suspected abuse or neglect to the resource nurse and then that information would have been reported to the nurse supervisor.
*RN Q would have interviewed the patient and PCT to obtain further information regarding the allegation of sexual abuse.

Review of staff education for RN Q and PCT Y revealed they both had completed training on patient rights and abuse/neglect in May 2023.

Interview on 7/6/23 at 8:35 a.m. with RN Q regarding reported alleged sexual assault to patient 1 revealed:
*RN S had informed her that patient 1 had felt violated by PCT Y and that PCT Y had been reassigned to another area on the unit.
*She had asked RN S if patient 1 accused PCT Y of any sexual abuse.
-RN S stated patient 1 had felt violated by PCT Y.
*She had been aware that patient 1 had a history of sexual abuse by a male.
*She had monitored the situation but had not informed her supervisor or risk management of patient 1's feelings.
*She thought that a patient feeling violated was not serious enough to report to her supervisor or risk management.

Interview on 7/6/23 at 9:00 a.m. with RN K regarding patient 1 feeling violated by PCT Y revealed:
*Information that had been obtained by a staff member should have been reported to the supervisor and to risk management.
*Patients that had a history of sexual abuse, that information should have been in their chart as personal health information for staff to have been made aware.
.
Interview on 7/6/23 at 10:00 a.m. with patient care leader R regarding the above information from the complaint intake information and the interview with RN Q revealed:
*He had not been informed of patient 1 feeling violated by PCT Y.
*He had been the lead for that unit since June 2023 but had previously been a lead in the emergency room.
*He expected RN Q to inform him, the patient care representative, and risk management of patient 1 feeling violated.
*PCT Y should have been removed from performing patient care pending the outcome of an investigation.

Review of the provider's September 2021 Patient/Family Complaints and Advocacy Policy revealed:
*The policy establishes a procedure for channeling patient care related to complaints.
*Complaints were recorded in a database maintained by the patient representative coordinator.
-Complaints, concerns, or requests for assistance were channeled to the appropriate department, director/manager for investigation and a resolution.
*Complaints were given proper consideration as a risk management issue.

Review of the provider's April 2023 Corrective Action policy revealed:
*Examples of when an employee should have been suspended pending a human resource investigation included, but were not limited to the following:
-A situation that involved allegations of abuse by an employee.
-A situation where the employee needed to have been removed to conduct a thorough investigation.

Based on a review of the South Dakota Department of Health (SD DOH) complaint intake information, observation, interview, job description review, and policy review, the provider failed to ensure pharmacy services implemented a security process following the misappropriation of use for both controlled and non-controlled medications in one of one intensive care unit (ICU) by one of one registered nurse (RN) (A).

These failures have the potential for misappropriation of medications to continue since no processes or policies had been changed.

NOTICE:
On 7/6/23 at 2:45 p.m. facility chief executive officer O was informed of an Immediate Jeopardy (IJ) for failure to ensure a security process had been implemented and updated following a drug diversion of four bags of Fentanyl and twelve bottles of Propofol.

PLAN:
The facility provided the following acceptable removal plan on 7/12/23 at 1:30 p.m. for pharmaceutical services:

1. "Turn on Blind Counts (this is a pyxis setting where all users, that pull the medication, physically count the contents of the pocket prior to medication removal) for Propofol in the Pyxis 7.12.23 @ [at] 0800 [8:00 a.m.].
*Notification will be sent via Voalte, Email and Daily Lineup, on 7.11.23 about new process.
*Pharmacy will send to the Patient Care Leaders, Certified Nurse Educators, Supervisors, and Pharmacy staff."

2. "Change waste requirement of propofol to pyxis (like narcotics process) on medical units with destruction in CSRX [Stericycle's medication waste container]."
*Inform staff of the change in waste of propofol, 7.11.23.
*Voalte message will be sent, Daily lineup, Friday updates by Managers, Email, and Quality Boards.
*Labels will be made and attached to the CSRX bottle to include Propofol, completed 7.10.23."

3. "Run list of Pyxis Medications pulled without a corresponding admin for high-risk diversion medications.
*Report validation to occur this week, complete 7.12.23.
*Pharmacy will contact Leader with the report. After the leader reviews report, they then can move forward with investigation of the lack of documentation of administration. If the employee is unable to explain and show documentation of rate via the I [intravenous flowsheet. Corrective action and continued monitoring will be set for the the individual employee with all future occurrences of administration.
*Report will be sent to the nurse leaders daily for 3 months and revisit to continue to evaluate documentation and administration.
*Implementation to begin 7.12.23."

4. "Drug Diversion Investigation Response Team (DDIRT) - we recognize that medications are a patient safety and employee safety issue. DDIRT is a component of our Patient Safety process to deliver and understand an individual's performance within our institution as it relates to substance abuse or medication diversion as directed by the Regional Controlled Substance Oversight Committee. It is an investigative arm to the Regional Controlled Substance Oversight Committee.
* DDIRT meets on an ad hoc [as needed] basis to review specific instances of potential medication diversion - Activated by anyone that has a concern of a diversion, leaders, as well as surveillance tools.
*Education to all leaders involved in distribution and administration of medications @ 7.11.23 @ 0900 [9:00 a.m.].
-Education has been rolled out, 7.12.23, to staff at every shift as well as on Healthstream, 7.12.23, to complete prior to their shift beginning.
*Meetings and Minutes will include action plan and follow up plan.
*Report out to Regional controlled Substance Oversight Committee meeting, Patient Safety and Pharmacy and Therapeutics-Quarterly.
*Risk Management report out to Avera McKennan Quality Committee and Patient Care Leaders."

The removal plan for the IJ was received and accepted on 7/12/23 at 1:30 p.m. On 7/13/23 at 11:00 a.m. the implementation of their plan was verified and the Immediate Jeopardy status was removed while the surveyors were onsite.

Findings include:

1. Review of the provider's 6/14/23 final incident report investigation submitted to the SD DOH on suspicion of misappropriation of meds by RN A for both controlled and non-controlled meds revealed:
*The report was submitted to the SD DOH 14 days after the identification and suspicion of the drug diversion had occurred.
-An initial report should have been submitted to the SD DOH within 24 hours of the identification of the suspicion of drug diversion.
*He had been employed with the facility since 9/6/20.
*A co-worker had brought forward a report suspecting him of diverting (stealing) drugs.
*An investigation was opened on RN A for a possible drug diversion.
*RN A:
-Required disciplinary action and he was terminated on 5/31/23 for reasonable suspicion of drug diversion that occurred from 2/4/23 through 4/24/23.
-Admitted to poor and sloppy documentation, but had not admitted to diverting any drugs.
*Through the provider's investigation the following list of meds had been unaccounted for:
-Fentanyl (pain medication) 4 bags. There was no documentation to support the dosage of the med nor the milliliters (ml) in the bags.
-Propofol (anesthetic used for sedation) 12 bottles [vials]. There was no documentation to support the size and amount of medication that was in those vials.
*"Through the investigation, we do not believe any patients were harmed as a result of this employees activities."
-There was no documentation to support how the investigation had been completed to support no harm to the patients had occurred.
*The abuse/neglect allegation for RN A was not substantiated since he had not admitted to the diversion of those meds.
*The action taken by the provider to ensure a drug diversion of that magnitude would not occur again was to terminate RN A.
*There was no documentation to support the following:
-Facility procedures and processes for drug security had been reviewed or revised to ensure the diversion of meds would not occur again.
-Personnel education or re-education on the current or revised policies for med security had been completed.

Observation and interview on 7/6/23 at 8:10 a.m. with RN D, RN G, and pharmacist H in the medication dispensing and wasting area of the emergency department (ED) revealed:
*The room was large and had several unidentified staff members working in the room on computers and various other activities.
*Some of those areas and staff were located approximately 5 feet (ft) from the Pyxis (automated medication dispensing machine) and biohazard waste containers.
*There were three biohazard waste containers located right next to the Pyxis.
-The containers were approximately 2 ft tall with large openings on the top of them. The lids attached to the openings could have been opened manually or with a foot-activated device. The opening was large enough to put a hand inside of it.
-Inside those containers were multiple vials, intravenous tubing (IV), and syringes.
-Those containers were used for wasting non-controlled meds that had not require 2 people for wasting meds.
*One of the containers was 3/4 full and had a small syringe laying on top of the contents.
-It was 3/4 full of a white liquid substance and was labeled Propofol.
*The contents inside of the vials, syringes, and the tubing were not required to have been wasted prior to placing them into the containers because they were non-controlled meds.
*They agreed some of the meds could have had a negative outcome should they have been handled inappropriately.
*They were not aware of any recent education or process changes for the security of meds and drug diversion.
-Stated: "Not anything outside of our yearly mandatory training on that which we just had to complete."
*The pharmacist stated:
-"Those meds are non-controlled and don't need a witness for wasting."
-"Propofol is not a controlled substance so therefore, does not require a witness for wasting and can be put in that container."
-"I'm not aware if Propofol is a highly diverted or high-risk med or not."
-"Controlled substances require two people to waste and we do that in the SteriCycle container over there on the wall."
*The staff had the capability to override the system in emergency situations when the physician had not entered an order in the system for a STAT (immediately) med.
*If a staff member was not available to waste a controlled substance the system would leave it open and incomplete.
-Per the pharmacist, those were reviewed for appropriateness.
*The surveyor requested the provider's policy on the process for med destruction and accountability for non-controlled substances.

Observation and interview on 7/6/23 at 8:45 a.m. with RNs G and I in the medication dispensing and wasting area for the Pediatric Intensive Care Unit (PICU) revealed:
*We entered an unsecured room where the Pyxis machine and the biohazard medication waste containers were located.
-The room was clean and contained multiple patient use items.
-Housekeeping, maintenance, and all staff had access to the room.
-Housekeeping and maintenance would have removed the biohazard waste containers after they were full.
*RN I confirmed all controlled substances required:
-A second person for wasting the meds into the SteriCyle biohazard waste container.
-The staff would complete a count upon the removal of any medication and prior to closing and locking the Pyxis.
-All non-controlled meds should have been placed in the two large biohazard containers sitting on the floor next to the Pyxis.
*Propofol was used in the PICU for conscious sedation prior to any procedures.
*One of the large biohazard waste containers:
-Was full of vials, syringes, and IV tubing. All of them had some type of medication left in them.
-Had a 30 cubic centimeter (cc) syringe 1/2 full of a white substance and was labeled Propofol.
-Had multiple IV tubing in it and were full of a white substance. RN I confirmed the substance would have been Propofol.
*RN I:
-Confirmed that Propofol was a high-risk medication due to its mind-altering affects.
-Was aware that Propofol was a highly diverted med.
-Agreed all meds should have been accounted for from the time they enter the facility to when they are utilized by the patient.
-Stated:
--"It's not controlled so we just put it in that large bin. We don't have to waste it and we just throw it and other meds in those bins."
--"Yep, anyone can reach in that bin and take what they want."
-Agreed that housekeeping and maintenance were not considered authorized staff to have been handling wasted medication.
*She was the lead supervisor for the area and any medication discrepancies were given to her for review and follow-up.
*There recently was a discrepancy with a controlled substance that was created by a nurse.
*RN I stated:
-"The nurse had entered the wrong number after she did a count of what was left in the Pyxis."
-"Instead of correcting it or reporting it to the supervisor, she just did an override on it."
-"The system will let you know there is a discrepancy, but you can override it and that's what she did."
-"Two other staff came behind her and the system showed an error, they entered the right count, but just did an override and kept working."
-"It was two nurses deep into the discrepancy before it was caught."
-"Not sure what the process for review on that would be. We just get handed the reports to figure out what happened."
-"The nurse should have either gotten a supervisor to help or reported it if she couldn't fix it at that time."
-"No, we have not had any changes in processes for med security and diversion that I'm aware of."
-"No, no education on anything like that recently, nothing extra outside of our mandatory training. We did recently have to do that."
-"As the supervisor I would have known and helped with any educating."

Interview on 7/5/23 at 2:40 p.m. with pharmacist E revealed he:
*Was the pharmacy manager for inpatients and assisted the pharmacy director in his absence.
-The pharmacy director was currently on vacation.
*Confirmed the observed processes above for both the controlled and non-controlled meds for wasting and accountability.
*Was not aware of any drug diversion concerns recently and typically would not have been involved with them.
*Would have pulled reports when asked to help with the review, but otherwise, no involvement with that process.
*Stated:
-"My role is specifically within the pharmacy. If there is an issue with drug diversion or accountability, the unit leaders would handle that."
-"I do not work directly with the nursing staff, the unit leaders do that."
-"We have a controlled substance coordinator and she would take the lead on any changes there."
-"[Controlled substance coordinator's name] and the pharmacy director work together on the drug diversion issues."
-"I'm not aware of any recent drug security concerns and usually I don't know. I'm not privy [privileged] to that information."
-"I don't know of any process changes for med security or recent education on changes."
-"We do have a drug diversion investigation response team (DDIRT) and the controlled substance coordinator J takes the lead on that."
-"There have been discussions on treating Propofol as a controlled substance, but that's all I know, so I can't speak to any process changes specifically for that."
-"Propofol is not considered a high alert or high-risk med. All meds have the capability of having a negative outcome if handled inappropriately. It's not controlled so it's not monitored as closely."
*Frequently deferred his answers to check with the controlled substance coordinator on med security processes for both the controlled and non-controlled substances.
*Confirmed that the Pyxis system had an override capability but should have been used in emergent cases only.
*Discrepancy audits would have been completed on a daily basis.

Interview on 7/6/23 at 9:25 a.m. with controlled substance coordinator J revealed:
*She confirmed:
-She and the pharmacy director took the lead on drug diversion reviews for the DDIRT and made recommendations for any required changes from those reviews.
-The staff had the capability to override the system, but in emergent situations only. To her knowledge that was the only time it was or should have been used.
-There had been a recent drug diversion investigation on the intensive care unit.
*She stated:
-"It was a hard diversion to review, he didn't document administrations, or end times, his scanning rate was 62% and should have been 95% or greater."
-"We reviewed 29 charts on patients that he cared for and had orders for Fentanyl or Propofol."
-"His documentation was so poor that I had to have pharmacy help look at drip times to tell when the bags ended. Then we could see when he should have started a new bag."
-"The Fentanyl was easier to track because it's a controlled substance but Propofol isn't and there's no blind count [required count upon removal of the med from the system]."
-"Propofol is not a controlled substance so technically we don't have to monitor that one closely."
-"We increased our auditing for staff scanning, but we were doing that before this happened. They should scan the med with administration. He was not doing that or documenting administrations."
-"No there was nothing changed or re-education on med diversion because we just had it in May."
*She was not aware the override capability had been used by the staff for other purposes than emergent situations and should have been.
*The investigation consisted mostly of chart review versus process review for a potential need in change with them.
*Staff documentation had been the biggest concern with that case.
*There was no documentation from the DDIRT to support:
-They had reviewed internal security and accountability for both controlled and non-controlled wasting processes.
-A full investigation had been completed to determine a root cause analysis for the diversion.
-What was implemented, reinforced, or changed with current policies and processes to ensure a drug diversion of that magnitude would not occur again.
*The provider had relied upon the mandatory training on drug diversion to educate the staff vs taking an active role for that concern.
*She stated:
-"With The Joint Commission we have 45 days to complete a root cause analysis on our occurrences."
-"We only looked at the Propofol for diversion because there was so much taken."
-"We did get together and did a debrief on this to see what we could have done better. No, I don't have documentation to support that."
-"When I was completing the 106 Form [Drug Enforcement Administration form] was when I recognized we probably should be doing more."
*She agreed the incident report that had been submitted to the SD DOH was 14 days late.
*Surveyor requested the provider's policy on the process for med destruction and accountability for non-controlled meds.

Review of the 5/31/23 Drug Enforcement Administration (DEA) form 106 revealed:
*It supported:
-There had been an employee theft and when it was first discovered on 5/31/23.
-There was no documentation to support why the law enforcement had not been notified.
*The corrective measures the provider had implemented to prevent future theft or loss had been:
-"Increased employee monitoring."
-"Provided security training to the staff."
-"Pandemic and Health emergency relaxations surrounding documentation have recently been reversed (tightened) on the unit in question. Additional training for staff and higher expectations of documentation are added to procedural guidelines."
*The form requested to enter additional remarks if required. The following documentation from the provider was added:
-"Description of how theft or loss occurred."
-"Several bags of propofol and fentanyl had lacked documentation."
-There was no description on how their investigation identified that documentation in the eMar (electronic medical record) was a contributing factor for the drug diversion.

Through interviews, process reviews, and document reviews, there was no evidence that all those corrective measures documented on the DEA form 106 had:
-Identified areas of concern.
-Been implemented.
-Been changed on any policies, processes, or guidelines provided to the surveyor for review.
-Required staff education on those new and implemented process changes.

Interview on 7/6/23 at 3:10 p.m. with chief compliance officer C revealed:
*The DDIRT was a committee developed to specifically review drug diversions and they only met when a suspected diversion occurred.
*She agreed:
-A full investigation had not been completed to determine the root cause of the drug diversion
-There were no processes reviewed for possible change to ensure the removal of the drug diversion risk had occurred.
-Emails and only chart reviews would not have been considered a complete and full investigation.
-There should have been documentation to support what actions or process changes they had considered changing and why.
-After the review, the provider was still at risk for a drug diversion to occur.
*Surveyor again requested the provider's policy on the process for med destruction and accountability for non-controlled substances.

Interview on 7/6/23 at 4:45 p.m. with Accreditation Manager D revealed:
*Propofol should have been considered a high-risk med because it was known to have been highly diverted.
-There should have been process changes reviewed and implemented for the accountability and security of that med.
*She confirmed:
-The staff who worked in the ED and PICU had viewed the Propofol and the security of that drug as nothing to worry about because it was not a controlled substance.
-With the current waste process for the Propofol in the large waste containers created the potential for drug diversion.
*Surveyor again requested the provider's policy on the process for med destruction and accountability for non-controlled substances.

Review of the 12/15/20 director of hospital pharmacy job description revealed:
*"Directs the procurement, storage and distribution of pharmaceuticals and the dissemination of pharmaceutical product information....."
*"Responsibilities include......evaluating department performance and implementing appropriate improvement plans; ....... and addressing complaints and resolving problems."
*"Maintains and recommends enhancements to department policies and procedures governing all pharmacy operations and monitors implementation and compliance with hospital-wide policies."

Review of the 3/12/19 pharmacy manager job description revealed:
*Oversees the clinical and distributive pharmacy services for the pharmacy in accordance with professional standards, regulatory and licensing agency policies, and federal and state laws related to the practice of pharmacy."
*"The manager must utilize effective problem solving skills as appropriate and accept personal responsibility and accountability for the patient's and department's outcomes."
*"Responsibilities include....evaluating department performance and implementing appropriate improvement plans;.....and addressing complaints and resolving problems."

Review of the provider's August 2021 Medication Administration policy revealed:
*"Medication administration is documented after the medication is administered."
*"High alert medications are medications involved in a high percentage of errors and/or sentinel events as well as medications that carry a higher risk for abuse or other adverse outcomes."
*There was no documentation to support the process for wasting both controlled and non-controlled medications in vials, IV bags, IV tubing, and syringes.

Review of the provider's June 2021 Monitoring Controlled Substance Utilization and Documentation policy revealed:
*"To ensure the safe and appropriate utilization of controlled substances while describing the standardized review process for proactive and retroactive review that may identify potential drug diversion or unaccounted for controlled substances within the organization."
*"Each Avera facility should have a Drug Diversion Investigation Response Team (DDIRT) in place to evaluate any suspected drug diversion."
-There was no documentation to support a process was in place for the DDIRT to follow when investigating a suspected drug diversion.
*Escalation:
-"Department of Criminal Investigation or local law enforcement will be contacted ........"
-"The following reports shall be filed by the pharmacist-in-charge or other designated pharmacy leader within 24 hours, or as soon as possible in accordance with federal and state laws and guidelines.
--a. Reporting to Licensing Board.
--b. Reporting to Board of Health [SD DOH].
--c. Notification to the DEA."

Review of the provider's December 2023 Pyxis ES [Enterprise Server] policy revealed:
*"Medication orders not on profile may be removed by override by the nurse during certain circumstances. The use of the override function will be guided by the condition of the patient. Appropriate use of the override function is defined as:
-The physician is present at the time the drug is administered OR
-The condition of the patient is such that the patient would be harmed by waiting for review of the medication (urgent situation)."
*"The pharmacy is responsible for review of medications removed by override. Variances in the use of override will be documented and reviewed with nursing leadership."
-There was no documentation to support how often the pharmacy completed these reviews.

A policy and procedure for the medication waste and destruction process for non-controlled substances was not provider to the survey team by the time of exit from the facility on 7/13/23 at 4:00 p.m.