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Based on record review and staff interview the facility failed to ensure that the Organized Medical Staff (OMS) bylaws are presented to the governing body for approval on an annual basis per the OMS bylaws.

Findings:

Review of the OMS Bylaws revealed that the last time they were adopted and approved by the OMS, and the approval page was signed, and presented to the governing body for approval was 12/7/2010.

Review of the OMS Bylaws further revealed under Section 10.9, titled "Bylaws Committee", subsection 10.9-2 "Duties" states, "The duties of the bylaws committee shall include: (a) Conducting an annual review of the OMS bylaws." Under subsection 10.9-3, "Meetings" states, "The bylaws committee shall meet as often as necessary at the call of its chair but at least annually."

During an interview on 7/31/2013 at 11 a.m., Staff A stated the facility could not provide written documentation, such as a current signature page, to show that the bylaws had been approved on an annual basis.

Based on facility documentation and staff interview the facility failed to ensure that the Chief Executive Officer (CEO) managed the hospital by failing to ensure that transfer agreements to other hospitals were reviewed per facility policy and procedure on an annual basis to ensure quality of care for patients/clients/residents.

Findings:

On 7/30/13, review of the facility's list of hospitals that patients/clients/residents are sent to for outside services showed 14 hospitals.

The facility policy and procedure titled, "Transfer Agreements" documented, "as required by law, we must have a transfer agreement with each community/specialty hospital that provides services for our clients. ... Each agreement is to be reviewed and approved on an annual basis."

Of the 14 hospitals listed, nine had no agreements in place. Of the five remaining hospitals, two were last reviewed in 2007, two were last reviewed in 2008, and the fifth hospital agreement showed that it had expired in 2012.

During an interview on 7/31/2013 at 11:15 a.m., Staff A stated that the documentation presented was the current list of hospitals used by the facility for transfers.

Based on interview and record review, the facility failed to maintain an accurate accounting of the controlled drug supply in accordance with State and Federal laws and regulations to ensure the security and accountability of medications with a high potential for abuse.

Findings:

On 8/1/13, at 11 a.m., the "Change of Shift Controlled Count Signature Record" for July 2013 was reviewed. The instructions given on the Controlled Drug Count Signature Record indicated that....."Your signature verifies that all the controlled drug records are accurate." There were multiple areas on the Controlled Drug Count Record missing staff signatures.

During a concurrent interview with Staff B, Staff B stated that at each shift change, the off-going and the on-coming licensed staff count the controlled drug supply. After the count was completed, both licensed staff signed the count sheet indicating that the drug count was correct. Staff B stated there were missing signatures on the count record and that she had not noticed the missing signatures until that time.

On 8/1/13, at 11:20 a.m., the "Controlled Drug Tracking Sheet" for July 2013 was reviewed. There were multiple areas missing licensed staff signatures.

During a concurrent interview with Staff B, Staff B stated that the Controlled Drug Tracking Sheet was used to track medications delivered to the unit. Pharmacy assigned a tracking number to each controlled medication for the receipt and the return of the medication. Staff B stated that system was used to maintain an accurate listing of the controlled drugs and staff was aware of the importance of signing in and out for the medications. Staff B stated there were many blank areas where staff was to sign. She stated she was not sure why staff did not fill in the form like they had been trained to do.

On 8/1/13, at 1 p.m., the facility policy titled "Procedure M 605 - Controlled Drugs Accountability" dated April 2013 was reviewed.
Under step 4....."At each eight hour shift change, the off-going and the on-coming assigned licensed staff together make an actual count of the controlled drug supply. If the entries from the previous shift are missing on the controlled sheets, they are to be corrected immediately."

Based on interview and record review, the facility failed to report four incidents of drug administration errors to the Quality Assurance Program. Two of the four drug administration errors were not reported immediately to the attending physicians. These failures place patients at risk for potential adverse drug events.

Findings:

On 7/31/13, at 10 a.m., the facility document titled, "Medication Error Tracking Form" dated 7/8/13 was reviewed. The Medication Error Tracking Form indicated that Patient 1 was to receive Sertraline (a medication given to treat depression) 50 mg. at 8 a.m. The report indicated that the medication Sertraline was found by the day shift lead at 11 a.m., in the medication drawer. Nursing staff documented... "MD notified. Medication given late." Staff B documented on the Medication Error Tracking Form .... "Med's not to be left in drawer. Must be administered at time of preparation."

During a concurrent interview with Staff B, Staff B stated that the medication error which had occurred on 7/8/13 had not been reported to the Quality Assurance Department. Staff B stated, "I just have not had the time to do this yet."

On 7/31/13, at 10:20 a.m., the facility document titled, "Medication Error Tracking Form" dated 7/14/13 was reviewed. The Medication Error Tracking Form indicated that Patient 2 was to receive Lovenox (a medication given to prevent deep vein blood clots) 80 mg. given by injection, at 8 a.m. Nursing staff documented on the Medication Error tracking Form...."While doing the day to p.m. count at 2:40 p.m., one extra dose of Lovenox was found, which indicated that the day shift dose had not been given. No physician notification done. Medication returned to pharmacy."

During a concurrent interview with Staff B, Staff B stated she had not reported this medication error to the Quality Assurance Department. She stated she had obtained the accountability sheets from pharmacy that day and would review them

On 7/31/13, at 10:45 a.m., the "Medication Error Tracking Form" dated 7/17/13 was reviewed. The Medication Error Tracking Form indicated that Patient 3 was to receive Clobazam (a medication given to prevent seizures) 20 mg at 8 a.m. and 8 p.m. Nursing staff documented on the Medication Error Form...."While counting medications from the day shift to the p.m. shift, Clobazam 20 mg p.m. dose was missing. Wrong dose given. PM dose was ordered from pharmacy for refill for 8 p.m. dose without MD's clarification and order."

During a concurrent interview with Staff B, Staff B stated she had not reviewed this drug error incident until that day and had not reported that incident to the Quality Assurance Department.

On 7/31/13, at 11:15 a.m., the "Medication Error Tracking Form" dated 7/22/13 was reviewed. The Medication Error Tracking Form indicated that Patient 3 was to receive Topiramate (a medication given to prevent seizures) 100 mg at 8 a.m. and 8 p.m. Nursing staff had documented on the Medication Error Form that staff had made a transcription error and the medication time for the Topiramate was transcribed to be given at 8 a.m. The 8 p.m., dose time was not transcribed.

During a concurrent interview Staff B stated the mistake in transcribing the medication order resulted in one missed dose for the patient. She stated she had not yet reported the medication error to the Quality Assurance Department.

On 7/31/13, at 2 p.m., the facility policy titled, "Procedure M 601 - Medication and Treatment Administration Procedures" dated April 2013 was reviewed. Under step 8 ......"Medications shall be administered at the time of preparation and shall be administered by the same licensed person who prepared the dose." Under step 24...."Medication errors are to be reported to the supervisor immediately and recorded on a Medication Error Tracking Form."

On 7/31/13, at 2:30 p.m., the facility policy titled "Procedure M 613 - Medication Error Reporting" dated December 2012 was reviewed. Under step 1...."Notify the physician/HSS immediately."

During an interview on 8/1/13, at 11 a.m., Staff A stated that all medication errors were to be reported to the Quality Assurance Department immediately.