QA Investigation Results

Pennsylvania Department of Health
Health Inspection Results
Health Inspection Results For:

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Initial Comments:

This report is the result of a Federal Validation Survey conducted on October 16, 2018, through October 19, 2018, at Brooke Glen Behavioral Hospital. It was determined the facility was not in compliance with requirements of 42 CFR, Title 42, Part 482 - Conditions of Participation for Hospitals.

Plan of Correction:

482.23(c)(1), (c)(1)(i) & (c)(2) STANDARD

Name - Component - 00
(1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient's care as specified under §482.12(c), and accepted standards of practice.

(i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations.

(2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures.

Based on review of facility policies and procedures, observation and interview with staff (EMP), it was determined that the facility failed to ensure that medications/biologicals were maintained in accordance with approved facility ' s policies and procedures.

Findings include:

Review on October 16, 2018, of nursing policy " Medication Administration " revisited August 2015, revealed " Purpose: ... To ensure preparation, administration and documentation of medications as prescribed by the ordering physician ... 6. Medications are never to be pre-poured ... 9. The medications are poured and administered by the same nurse ... "

Observations on October 16, 2018, of the EAC (extended acute care unit) medication refrigerator at 12:10 PM revealed a reconstituted vial of Geodon, Inj 20 mg/ml, SDV (single dose vial) Further observation revealed the bottle was dated 10/15/18. There was no documented evidence for the person that reconstituted the medication.

Interview with EMP5, on October 16, 2018, at 12:15 PM confirmed the date written on the vial was the reconstitution date. Further interview with EMP5 confirmed the medication was " probable mixed and not given yesterday. " Further interview with EMP5 confirmed the beyond use date after reconstitution is 7 days.

Interview on October 16, 2018, at 2:00 PM with EMP7 confirmed it is not the policy of the facility to save injectable medications that were reconstituted and not administered right away. Further interview with EMP5 confirmed the medication should have been discarded immediately if was not administered.

Plan of Correction:

(1) The Director of Nursing reviewed and revised the hospital's Medication Administration policy #607. The policy now specifies that "Prepared medications are never left unattended". "If injectable medication needs to be reconstituted prior to administration (e.g., Geodon® IM, Zyprexa® IM), it has to be administered by the same nurse". "All poured and/or reconstituted medications not used immediately or refused by the patient must be immediately wasted by the nurse in appropriate waste container or returned to "pharmacy return" bin". (2) On 10/18/18 the RN responsible for error management of medication was provided 1:1 re-education counseling (3) The Director of Nursing provided additional training as part of nurse staff meetings to the proper disposal of unused medication (4) Continued compliance will be monitored by conducting a minimum of 30 monthly random medication room audit inspections to ensure correct management of medications occurs, per policy. (5) Director of Nursing will provide a monthly report of audit outcomes to the hospital's Quality Council until 100% compliance is found for 4 consecutive months.


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The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community.

The Physical Environment Condition was found to be out of compliance during a Life Safety Survey completed on October 22, 2018 . Further details are outlined in the Division of Life Safety Survey Report

Plan of Correction:

Corrective actions that specifically address each Life Safety report finding was submitted.