EISENHOWER MEDICAL CENTER

Report ID: UITE11.02, California Department of Public Health

Reported Entity: EISENHOWER MEDICAL CENTER

Issue:

Based on interview and record review, the facility failed to ensure one nurse (Registered Nurse [RN] 1) handled the home medications for one patient (Patient 1) according to the facility policy when she allowed the medications to remain at the patient's bedside instead of sending them to the pharmacy. This failed practice resulted in the medications being sent home with a different patient (Patient 2), and the potential for illness, untoward side effects, overdose, or death to Patient 2 if she took the medications.Findings:During an interview with the facility Privacy Officer (PO) on September 8, 2014, at 3:20 p.m., the PO stated Patient 1 was admitted to the facility as an outpatient in August 2014. The PO stated during the outpatient stay, Patient 1's family member brought her home medications to the facility and gave them to the nurse caring for the patient (RN 1). The PO stated the nurse documented and reconciled all of the medications, then gave them back to the family member to take home. According to the PO, the family member wanted the medications to stay at the facility, so the nurse placed them in a cupboard in the patient's room. The PO stated Patient 1 then became an inpatient, and was transferred to a different room.According to the PO, a different patient (Patient 2) was admitted as an outpatient to the room, and then became an inpatient and was transferred to a different room. The PO stated when Patient 2 was discharged home from the facility, the home medications for Patient 1 were found in her belongings bag that were sent home with her from the facility.A review of Patient 1's medications that were sent home with Patient 2 indicated they included the following:1. Norco (a narcotic pain medication), 160 tablets;2. Hydroxyzine (to treat anxiety), 45 tablets;3. Lorazepam (a narcotic used to treat anxiety), 107 tablets;4. Estradiol (for symptoms of menopause), 31 tablets;5. Duloxetine (an antidepressant), 12 tablets;6. Lasix (a water pill), 9 tablets;7. Diphen/Atropine (to treat diarrhea), 61 tablets;8. Alprazolam (a narcotic used to treat anxiety), 17 tablets;9. Potassium Chloride (to replace potassium), 19 tablets;10. Ketoprofen cream (to treat pain), 1 bottle;11. Potassium Gluconate (a potassium supplement), 23 tablets;12. Bupropion (an antidepressant), 20 tablets;13. Zolpidem (a sedative/hypnotic for sleeping), 24 tablets;14. D3 (to aid in calcium absorption), 11 tablets;15. Spiriva (a breathing treatment), 29 doses;16. Carisoprodol (a muscle relaxer), 27 tablets;17. Prochlorperazine (to treat anxiety), 34 tablets; and,18. Trazadone (an antidepressant), 10 tablets.The facility policy regarding disposition of patient's home medications was reviewed on September 8, 2014. The policy indicated if the patient's own medications were brought to the hospital, the nurse would encourage the patient to send them home with a relative or friend. According to the policy, if the patient was unable or unwilling to send the medications home, they were to be placed in a, "valuables," envelope, labeled, and sent to the pharmacy for storage until discharge.Failure of the nurse to follow the facility policy resulted in Patient 2 being sent home with Patient 1's medications, and the potential for illness, untoward side effects, overdose, or death to Patient 2 if she took the medications.

Outcome:

Deficiency cited by the California Department of Public Health: Nursing Service Policies and Procedures.

Related Reports:

The report containing this deficiency also includes information about 1 other violation. Note that these may be related to the same event: UITE11.01