HospitalInspections.org

Based on record review and interview the hospital failed to ensure the pharmacist supervise and coordinate all the activities of the pharmacy by failing to:

1) ensure physician ordered medications were available for administration for 1 of 6 sampled patients (#F2). Findings:

Patient #F2 was admitted to the hospital on 1/19/2010 and discharged on 1/15/2010 with diagnoses that included osteomyelitis, infected left foot, hypertension, and diabetes.

During a face to face interview on 3/15/2010 at 10:10 a.m., Patient #F2 indicated he had chronic pain which involved the receipt of two different medications to control the pain. #F2 indicated he received Morphine for generalized body pain and received Levorphanol for neuropathic pain to his lower extremities. #F2 complained that he had not received any of the Levorphanol for the entire weekend from Friday 12th until through the time of the interview on 3/15/2010 at 10:10 a.m. #F2 complained that he had not been able to sleep due to the sensation of a hot rod being shoved from his foot through his leg into his thigh. #F2 indicated he had been informed by nursing staff that Levorphanol was not available due to being on back order. #F2 indicated his physician had visited him over the weekend and said that the patient could take his home medication Levorphanol for pain; however, it was locked in the Assistant Administrator's (S1) office who was out of town and there was no one with keys to obtain the medication for administration. F2 indicated that although he received Morphine for other pain, it had not helped with his neuropathic pain in his legs.

Review of Patient #2's Physician's orders included the following:
1/19/10 at 1700 (5:00 p.m.): Levorphanol 2 milligrams by mouth every 8 hours prn (as needed) and Morphine CR 30 milligrams by mouth every 4 hours prn (no indication)
1/20/10 at 3:20 p.m.: Morphine Sulfate 30 milligrams every 4 hours prn pain.
1/23/2010 at 12:30 p.m.: Levorphanol 2 milligrams by mouth every 6 hours prn pain.

During a face to face interview on 3/15/2010 at 11:40 a.m., Director of Nursing S2 indicated Patient #F2 had home medication, which included 11 tablets of Levorphanol 2 milligrams, locked in the Hospital Assistant Administrator's office. S2 confirmed the hospital had a policy which would have allowed #F2's home medication to be administered to the patient if ordered by the physician and if the medication was identified and labeled by the pharmacist prior to administration. S2 indicated; however, that the medication could not have been accessed by hospital staff because it had been locked in the Assistant Administrator's (S1)office since his admission on 1/19/2010 and the Assistant Administrator had been out of town (with the key). The Director of Nursing further indicated there had also been 25 tablets of Levorphanol 2 milligrams removed from the stock narcotic box on 3/11/2010 and placed in a locked box in her office (S2). The Director of Nursing indicated this had occurred because the hospital had lost their Controlled Dangerous Substance license and could only administer medications that were prescribed specifically for an individualized patient. The Director of Nursing indicated there had been no attempt to send the narcotic floor stock back to the pharmacy in order for the pharmacist to dispense the medication specifically for Patient #F2.

During a telephone interview on 3/16/2010 at 9:10 a.m., the Director of Pharmacy S13 indicated he could have made the floor stock of Levorphanol available for Patient #F2 if it had been returned to pharmacy when it was pulled from floor stock. S13 further indicated the patient's home medication (Levorphanol) could have been used to administer to Patient #F2 according to hospital policy, if the physician ordered it's use and if the medication had been sent to the pharmacy for identification and labeling. S13 indicated there had been no attempt by the pharmacy department to have the stock Levorphanol returned to the pharmacy in order to ensure it was properly dispensed individually for Patient #F2 and available for administration as per physician's orders.

2) ensure narcotic medications were stored in an area not accessible to non-licensed staff for 1 of 1 bottle of Levorphanol reviewed for storage. Findings:

During a face to face interview on 3/15/2010 at 11:55 a.m., Assistant Administrator S1 confirmed that she had a bottle containing 11 tablets of the home medication Levorphanol locked in her office. S1 further indicated she had no license that would permit her to store or have access to narcotics stored in the hospital. S1 confirmed that this bottle of Levorphanol was located in her office from the date of 1/19/2010 until removed for administration to Patient #F2 on 3/15/2010. S1 further indicated it had been an oversight on her part and that the medications should have been stored in a double locked area for access by licensed personal only.



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