Observations
DDAP staff conducted an on-site investigation on March 24, 2017 which included a review of the patient's record and the facility's Root Cause Analysis finding. Based on these findings, the facility failed to prescribe medications in accordance to the Physician's Desk Reference to prevent drug interactions. Additionally, the facility failed to follow an observation order issued by the physician.
According to the Montgomery County Coroner and Medical Examiner's Reports that were submitted to DDAP on March 10, 2017, the patient died of an overdose from a combined drug intoxication (Diazepam, Temazepam, Methadone, and Fluoxetine) and the manner of death was determined to be an accident. According to the Medical Examiner's Report: "All of the above drugs in the decedent's system are not at the toxic and/or lethal concentration, however; they all have synergistic affect in which the effect of each drugs increase by the three to four times of its effect alone."
A BIOP note dated November 14, 2016 indicated there was a standing order issued from November 12, 2016 for Q 1 safety checks every hour, however, there was no documentation of the purpose for the Q 1 safety checks, nor documentation that they occurred.
A BIOP note dated November 15, 2016 at 2:55 AM indicated the patient offered no complaints from the patient during this shift. The patient's Q 1 hourly safety checks were to continue, however, there was no documentation that these checks occurred.
|
Plan of Correction
Preparation and execution of a plan of correction does not constitute admission or agreement of the provider of the truth of facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.
The facility's practitioners will continue to ensure that prescribed medications are in accordance with the Physician's Desk Reference, as will the pharmacy. The Hospital's pharmacy management team will evaluate potential contraindications at the time orders are submitted and take actions as indicated. Findings will be monitored by the Pharmacy and Therapeutics Committee. Completion date August 10, 2017
Q 1 hour observations for this patient were conducted and documented appropriately but the facility concedes that copies were not provided at the time of the survey to the surveyors. The Quality Management and Medical Records departments have been in-serviced that DDAP survey requests for medical records information will ensure that observation sheets are retrieved and provided to the Department during future surveys, when appropriate. The Facility Director will ensure compliance. Completion date: August 15, 2017
|