RIVERSIDE COMMUNITY HOSPITAL

Report ID: VDGJ11.02, California Department of Public Health

Reported Entity: RIVERSIDE COMMUNITY HOSPITAL

Issue:

Based on observation, interview, and record review, the facility failed to ensure a written policy was developed and implemented to outline the process for safely and effectively dispensing, "hardship," medications to patients upon discharge (to provide a three supply of medications) when one patient (Patient 1) was sent home with medications dispensed for a different patient (Patient 2). This failed practice resulted in the potential for harm and death for Patients 1 and 2.Findings:During an interview with the facility HIPAA (Health Insurance Portability and Accountability Act) Manager on July 15, 2014, at 10 a.m., the manager stated two patients (Patients 1 and 2) were being discharged on the same day from the same unit, and both patients were to receive, "hardship," medications on discharge (enough medication to last three days). The manager stated when Patient 1 was discharged home, she was given a bag that contained the discharge medications for Patient 2.During an interview with the Director of the Medical Surgical floor (Med Surg) on July 16, 2014, at 9:40 a.m., the director stated two patients were being discharged from the floor on the same day that had orders for hardship medications to be dispensed at discharge. The director stated the floor received a call from the pharmacy to say the hardship medications were ready, so she took Patient 1 with her to the pharmacy, signed for the medications, and gave them to Patient 1 to take home. The director stated the nurse, questioned in her mind," why she had to sign so many slips for the medications, but she, "never pursued it any further." The director stated the second patient (Patient 2) went to the pharmacy to get his medications, and they were not there, and the nurse realized she had given the medications for Patient 2 to Patient 1.The director stated Patient 1 was only given a prescription for one hardship medication for discharge, and Patient was given 10. The director stated the nurse should have verified the medications she gave to Patient 1 were meant for Patient 1, and she should have discussed the medications with the patient.During an interview with the Quality Manager (QM), the QM stated the facility did not have a policy regarding dispensing hardship medications.During a tour of the pharmacy on July 16, 2014, at 11:30 a.m., accompanied by the QM and the Lead Pharmacy Technician (LPT), the LPT explained the process for receiving and processing an order for hardship medications. The LPT stated when the prescription was filled and ready to pick up, the nurse would come to the pharmacy to get the medications. The LPT stated on July 4, 2014, when Patients 1 and 2 were discharged, the nurse signed for both patients, and was given two bags with medications in them. The LPT stated the nurse signed for each medication individually.The book with labels signed off by nurses was observed next to the pharmacy window. A review of the book indicated the labels the nurses signed included only a patient name and a prescription number. There was no information to indicate to the nurse what medications they were signing for. During a concurrent interview with the LPT and the Pharmacy Informatics Administrator on July 16, 2014, at 11:45 a.m., both stated they did not have a written policy or procedure for processing and dispensing hardship medications. They stated when a new employee started working in the pharmacy, they learned the process from the person training them.The record for Patient 1 was reviewed on July 16, 2014. Patient 1, a 28 year old female, was admitted to the facility on July 2, 2014, with a diagnosis of acute opiate withdrawal. The record indicated the physician ordered one medication to be dispensed by the pharmacy as a hardship medication (subutrex to prevent or reduce opioid withdrawal).The record for Patient 2 was reviewed on July 16, 2014. Patient 2, a 57 year old male, was admitted to the facility on June 24, 2014, with a diagnosis of myocardial infarction (heart attack). The record indicated the physician ordered 10 medications to be dispensed by the pharmacy as hardship medications. Among the medications were the following:1. Atorvastatin - to lower cholesterol;2. Plavix - to prevent formation of clots that block arteries and cause heart attacks and stroke;3. Isordil - to relax the blood vessels and reduce the work load of the heart after a heart attack;4. Metoprolol - to lower blood pressure by lowering the heart rate;5. Aspirin - to prevent blood clots from forming; and,6. Norco - an opioid pain medication.Patient 1 was sent home with the 10 medications prescribed for Patient 2. The medications, if taken by Patient 1, had the potential for side effects of low heart rate and low blood pressure, bleeding, and relapse of her addiction (she was experiencing opiate withdrawal and was discharged home with opiate pain medications).If the medications were not available for and not taken by Patient 2, he had the potential for increase in blood pressure, increase in cholesterol, clot formation in his vessels, and increased risk of heart attack and stroke.

Outcome:

Deficiency cited by the California Department of Public Health: Pharmaceutical Service General Requirements

Related Reports:

The report containing this deficiency also includes information about 1 other violation. Note that these may be related to the same event: VDGJ11.01