HospitalInspections.org

Based on interview and document review, it was determined that for 1 of 10 (Pt #1) patients, the Hospital failed to ensure safe and appropriate tracking and control of medications which led to the facility sending a controlled substance home with the wrong pt.


Findings include:

1. Pt #1's record was reviewed throughout the survey. Pt #1's record indicated Pt #1 was admitted to Medical/Surgical unit on 1/7/25 for pneumonia. Pt #1 brought in a home medication, buprenorphine-naloxene (suboxone - a controlled substance for pain) to be administered because the Facility did not stock this medication. Pt #1 was admitted with an order for suboxone 8-2 mg sublingual tablet 1 tablet 2 times a day and then was changed on 1/8 at 6:25 PM to 1/2 tab 2 times a day. Per timeline notes from 1/10/2025, "(E#8), pharmacy manager, was notified that nursing had not located the medication and suspected it may have been sent home with the wrong patient. The RN contacted (wrong patient) and verified that (the wrong pt) had the medication. On 1/10/25, Med/Surg Director (E #14) was notified and went to pick up incorrect medication from the involved patient. (E #14) picked up medication and brought the medication to Pharmacy. (E #14) and (E #8) documented in the waste log and disposed medication in Rx (pharmaceutical) Destroyer Container. On 1/10/25, the Hospitalist (E#9) reordered medication." Pt #1's record indicated Pt #1 missed one dose of the prescribed suboxone on the evening of 1/9 due to "mishandling."

2. A policy titled, "Administration of Drugs: Patient's Personal Drugs" was reviewed on 3/3/25. It stated, "Discharged patients: Drugs belonging to discharged patients shall be returned to the patient, adult family member, or adult significant other upon the patient's discharge ..."

3. On 3/4/25 at 1:00 PM , an interview was conducted with Registered Nurse (E #15). E#15 reviewed Pt#1's record and confirmed that she failed to use correct patient identifiers when sending home medication to discharging patient and Pt #1's suboxone was sent home with the wrong pt and should not have been.