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A. Based on policy review, video observation and staff interviews, it was determined the facility failed to provide care in a safe setting by allowing a Registered Nurse, who is in the WV Restore Monitoring Program, to handle narcotics on the Pediatric Pulmonary Unit (PPU). This has the potential to negatively impact the care given to all patients admitted to the facility for treatment.

Findings include:

1. The policy Job Description for Registered Nurse, last approved 06/14, was provided for review. Job technical profiency states in part: "Demonstrates knowledge of and compliance with all policies including but not limited to medication administration."

2. The policy Medication Administration, last approved 08/18, was provided for review. Administration of Medication states in part: "All medications are to be administered only by medical, nursing, respiratory or therapy personnel (in accordance with licensure)."

3. Review of medication room video footage on 12/05/18 at 9:17 a.m. revealed Registered Nurse (RN) #1 handed a morphine, fifteen (15) mg tablet and an oxycodone, ten (10) mg tablet to RN #2. In the video it was observed RN #1 then walked off the unit leaving RN #2 in possession of the narcotics. RN #2 is in the WV Restore Monitoring Program with a restricted license and cannot handle narcotics.

4. An interview was conducted with the Chief Nursing Officer on 12/05/18 at 11:14 a.m. She stated: "It is our expectation the RN who is supervising the staff member in the WV Restore Monitoring Program would not hand them narcotics to administer to patients". She concurred with the findings.

B. Based on video observation and staff interviews, it was determined the facility failed to have a policy reflecting guidelines to be used when a Registered Nurse in the WV Restore Monitoring Program is working on a patient unit and cannot have access to narcotics. This has the potential to negatively impact the care given to all patients who are admitted to the facility for treatment.

Findings include:

1. Review of medication room video footage on 12/05/18 at 9:17 a.m. revealed Registered Nurse (RN) #1 handed a morphine, fifteen(15) mg tablet and an oxycodone, ten (10) mg tablet to RN #2. In the video it was observed RN #1 then walked off the unit leaving RN #2 in possession of the narcotics. RN #2 is in the WV Restore Monitoring Program with a restricted license and cannot handle narcotics.

2. An interview was conducted with the Chief Nursing Officer on 12/05/18 at 11:14 a.m. She stated: "It is our expectation the RN who is supervising the staff member in the WV Restore Monitoring Program would not hand them narcotics to administer to patients. We don't have a policy reflecting guidelines for this situation." She concurred with the findings.

A. Based on staff interviews it was determined the facility failed to notify the hospital Quality Assurance/Performance Improvement (QA/PI) coordinator of the incident involving the Registered Nurse, who is in the WV Restore Monitoring Program, having access to narcotics on the Pediatric Pulmonary Unit (PPU). This has the potential to negatively impact complaints and grievances reported by staff or patients and prompt resolution of the complaints and grievances.

Findings include:

1. An interview was conducted with the Director of Quality and Risk Management on 12/05/18 at 8:30 a.m. She stated: "I was unaware of the complaint. I usually get an email in regards to the incident but an incident report was never completed. I couldn't notify the QA/PI coordinator of the incident because I was never made aware of the issue." She concurred with the finding


B. Based on policy review and staff interviews, it was determined the facility failed to follow their own policy regarding risk management findings being reported to the Quality Committee and Governing Body for one (1) out of one (1) complaint reviewed. This has the potential to negatively impact all patients who file a complaint or grievance with the facility.

Findings include:

1. The policy Electronic Event Reporting, last approved 07/18, was provided for review. The Quality Committee has delegated the task of investigation of adverse events to the Director of Quality Risk (DQR) and the DQR may designate individuals to assist with these investigations as needed. An event report must be completed in a timely manner, as close in real time to the event as possible. It is preferred the event report be completed by the employees with the most knowledge of the event, e.g., the employee who witnessed the event or who discovered the event.

2. The policy Patient and Customer Complaint or Grievance, last approved 07/18, was provided for review. Data from the patient complaint and grievance process will be compiled and reported to the Quality Committee and Governing Body on a quarterly basis.

3. An interview was conducted with the Director of Quality and Risk Management on 12/05/18 at 8:30 a.m. She stated: "I was unaware of the complaint. I usually get an email in regards to the incident but an incident report was never completed. There was no investigation completed. She concurred with the findings.

Based on policy review and staff interviews, it was determined the facility failed to ensure patient care was rendered in accordance with accepted standards of nursing practice and hospital policy by allowing a Registered Nurse, with a restricted license, to have access to narcotics on the Pediatric Pulmonary Unit (PPU). This has the potential to negatively impact all care given to patients on the unit.

Findings include:

1. The policy Job Description for Registered Nurse, last approved 06/14, was provided for review. Job technical profiency states in part: "Demonstrates knowledge of and compliance with all policies including but not limited to medication administration."

2. The policy Medication Administration, last approved 08/18, was provided for review. Administration of Medication states in part: "All medications are to be administered only by medical, nursing, respiratory or therapy personnel (in accordance with licensure)."

3. An interview was conducted with the Chief Nursing Officer on 12/05/18 at 11:14 a.m. She stated: "It is our expectation the RN who is working on the unit would know the policies for medication administration and would abide by the policy by not giving an RN, with a restricted license, access to narcotics." She concurred with the findings.

A. Based on document review, video observation and staff interviews, it was determined the facility failed to follow the policies outlined in the WV Restore Monitoring Program and to ensure the competence of the nursing staff available on the Pediatric Pulmonary Unit by allowing a Registered Nurse, with a restricted license, to have access to narcotics. This has the potential to negatively impact the care given to all patients on the unit.


Findings include:

1. Review of the WV Restore Program contract for the nurse in question states in part: "Employment Expectations: Your nursing position must include direct supervision by an RN who is:
1) aware of your WVR participation
2) working on the same premises or unit
3) readily available to provide assistance and intervention
4) unencumbered license
Controlled Substance Restriction (12 months): You may not have access to or administer any controlled/locked(Schedules I-V) medications that are mood/mind altering for a period of one year after you return to clinical nursing."

2. Review of medication room video footage on 12/05/18 at 9:17 a.m. revealed Registered Nurse (RN) #1 handed a morphine, fifteen(15) mg tablet and an oxycodone, ten (10) mg tablet to RN #2. In the video it was observed RN #1 then walked off the unit leaving RN #2 in possession of the narcotics. RN #2 is in the WV Restore Monitoring Program, with a restricted license, and cannot handle narcotics.

3. An interview was conducted on 12/05/18 at 10:30 a.m. with RN #1. She stated: "I didn't know what the program actually is and what she is actually allowed to do or not do in the program. We haven't had any guidance with the WV Restore Program and there is no policy about the program. I did give her the narcotics because I didn't know she wasn't allowed to handle them." She concurred with the findings.

B. Based on policy review, video observation and staff interviews, it was determined the facility failed to render patient care in accordance with their own policy regarding medication administration by allowing a Registered Nurse, with a restricted license, have access to narcotics. This has the potential to negatively impact all care given to patients who are admitted to the Pediatric Pulmonary Unit (PPU).


Findings include:

1. The policy Medication Administration, last approved 08/18, was provided for review. Administration of Medication states in part: "All medications are to be administered only by medical, nursing, respiratory or therapy personnel (in accordance with licensure)."

2. Review of medication room video footage on 12/05/18 at 9:17 a.m. revealed RN #1 handed a morphine, fifteen (15) mg tablet and an oxycodone, ten (10) mg tablet to RN #2. In the video it was observed RN #1 then walked off the unit leaving RN #2 in possession of the narcotics. RN #2 is in the WV Restore Monitoring Program and has a restricted license and can't handle narcotics or have access to them.


3. An interview was conducted with the Chief Nursing Officer on 12/05/18 at 11:14 a.m. She stated: "It is our expectation the RN who is working on the unit would know the policies for medication administration and would abide by the policy by not giving an RN, with a restricted license, access to narcotics." She concurred with the findings.

A. Based on policy review, video observation and staff interviews, it was determined the facility failed to follow their own Medication Diversion Prevention policy by not ensuring drugs and biologicals were controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law and by allowing a Registered Nurse (RN), who is in the WV Restore Monitoring Program, have access to narcotics on the Pediatric Pulmonary Unit. This has the potential to negatively impact the care given to all patients receiving medications on the unit.

Findings include:

1. The policy Medication Diversion Prevention, last approved 06/18, was provided for review. Section IX. Obtaining Medication for Administration states in part: "1. Patient specific controlled substances may be removed from the designated storage by an authorized person pursuant to a physician's order. Once obtained, controlled substance must stay in the possession of the person who signed them out and will administer the medication."


2. Review of medication room video footage on 12/05/18 at 9:17 a.m. revealed RN #1 handed a morphine, fifteen (15) mg tablet and an oxycodone, ten (10) mg tablet to RN #2. In the video it was observed RN #1 then walked off the unit leaving RN #2 in possession of the narcotics. RN #2 is in the WV Restore Monitoring Program, with a restricted license, and cannot handle narcotics.


3. An interview was conducted with the Director of Pharmacy on 11/05/18 at 12:05 p.m. She stated: "I was never told about this incident. We have a separate category for nurses who are not allowed to pass narcotics and we assign them a restricted username and password so they can not pull narcotics from the pyxis. The RN's on the unit know better than to give a nurse, with a restricted license, access to narcotics." She concurred with the findings.



B. Based on video observation and staff interviews, it was determined the facility failed to have nursing policies and procedures and safe practices used in the retraining of a staff RN while using the WV Restore Monitoring Program. This has the potential to negatively impact the care given to all patients admitted to the facility.

Findings include:

1. Review of medication room video footage on 12/05/18 at 9:17 a.m. revealed RN #1 handed a morphine, fifteen (15) mg tablet and an oxycodone, ten (10) mg tablet to RN #2. In the video it was observed RN #1 then walked off the unit leaving RN #2 in possession of the narcotics. RN #2 is in the WV Restore Monitoring program, with a restricted license, and cannot handle narcotics.

2. An interview was conducted with the Chief Nursing Officer on 12/05/18 at 11:14 a.m. She stated: "It is our expectation the RN who is supervising the staff member in the WV Restore program would not hand them narcotics to administer to patients. But we don't have any policies or safe practices reflecting guidelines for this situation." She concurred with the findings.