HospitalInspections.org

Based on Louisiana Administrative Code, contract review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice, consistent with state law. This deficient practice was evidenced by failing to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist, before the first dose was dispensed, for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications. Findings:

Review of the Louisiana Administrative Code, Professional and Occupational Standards,
Title 46: LIII, Pharmacist, Chapter 15, Hospital Pharmacy, §1511. Revealed in part:
Prescription Drug Orders, A. The pharmacist shall review the practitioner's medical order
prior to dispensing the initial dose of medication, except in cases of emergency.

Review of the hospital's policy titled, Consulting Pharmacist, revised March 2012 revealed
no provisions for the Consulting pharmacist to review medications before the first dose was
dispensed and administered.

In an interview on 04/05/16 at 10:10 a.m. with S4Pharmacy Manager stated that the hospital did not have a specific policy for first dose review. S4Pharmacy Manager further stated that the Pharmacist had access to the hospital's electronic records system during the day, but after hours the nurse's checked the medications by verifying with two nurses and then Pharmacy would review the next day.
In a telephone interview on 04/05/16 at 11:00 a.m. with S3Pharmacist confirmed that she did not perform first dose reviews on medications. S3Pharmacist further stated that two nurses verify the medications when ordered and she performed a retrospective review later.

Based upon record review and interview, the hospital failed to ensure a physician was appointed as the director of respiratory care services. Findings:

Interview with S2RN/Chief Nursing Officer (CNO) on 4/5/16 at 2:30 p.m. revealed S8Physician was identified as the physician director of respiratory care services.

Review of the Medical Executive Meeting Minutes for 2015 and S8Physician Credential File revealed there failed to be evidence S8Physician had been appointed as the director of respiratory care services.