INITIAL COMMENTS
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This report is a result of a follow-up to an incident that was reported by White Deer Run, Inc. Based on the findings of this investigation, the following deficiencies were identified.
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Plan of Correction
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709.32(c)(1) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication.
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Observations
A review of a patient record revealed that the facility failed to follow their protocol for admission in the application of medication standing orders. The patient record provided documentation that the patient received medication when the criteria established in the Librium protocol was not met.The findings include:In a review of patient record # 1, the facility's Librium Protocol For Admission stated that the administration of Librium should begin when the patient's Clinical Institute Withdrawal Assessment (CIWA) score is greater than 7. At 1440 (2:40 pm) on March 24, 2012, patient # 1 was assessed to have a CIWA score of 6 and received a dose of 100 mg of Librium. According to the identified protocol, facility staff assessing the patient were required to assess the patient to have a CIWA score of 7 prior to administering Librium to the patient. There was no documentation in the patient record that the physician was consulted regarding a change in the facility's protocol for dosing patient # 1 with Librium when the CIWA score registered 6.
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Plan of Correction
The Librium Protocol for Admission form has been revised (September 12, 2012) to include documentation which will support an order to administer Librium.
In the circumstance where a client is experiencing elevated vital signs, but a CIWA score is less than '7', a contact is made with the physician to report the vital signs and clients CIWA score. Based on these findings and if deemed medically appropriate, the physician may prescribe Librium.
Documentation in the chart must include date, time and initials of the Nursing staff discussing the case with the physician and upon the physician's arrival to the facility; the physician will date, time and sign the Librium Protocol for Admission Sheet.
The business day following the initial administration of Librium the Nurse Manager or their designee will review each chart to ensure that documentation is complete and present in the chart.
Noncompliance and/or incomplete charting at the time of the chart review by the Nurse Manager or their designee will result in a meeting with Medical Staff within 72 hours to discuss and correct as needed.
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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of the patient record, the facility failed to document that an initial urinalysis drug screen was reviewed by the facility's physician prior to induction. The findings include:Patient # 1 was admitted into treatment on March 23, 2012. Patient # 1 received a dose of 25 mg of methadone on March 24, 2012 at 12:30 pm. The documented results of the urinalysis indicated that the report was provided March 24, 2012 at 12:21 pm. There was no additional documentation that verified that the urinalysis results were made available to the physician prior to the administration of methadone.A review of the patient record revealed that the physician completed the examination on March 24, 2012, at 10:15 am. At the time of this examination, the results of the urinalysis drug screen were not yet available to the facility. The results of this test are essential to the physician's assessment of dependency and vital to the physician's determination of dosing orders. According to documentation provided by the facility, the results of the urinalysis were made available at 12:21 pm on March 24, 2012 and the patient was dosed at 25 mg of methadone on March 24, 2012 at 12:30 pm. There was no documentation in the patient record that verified that the physician was consulted regarding the results of the report prior to the administration of the first dose of methadone.
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Plan of Correction
Upon receipt of the electronic UDS results, a copy will be printed; nursing staff will review, date, time, and initial the results. The nurse will review results with the treating Physician. The nurse will be responsible for ensuring the results are filed in the client's record.
Nursing Staff will be trained on the above process no later than August 31, 2012. Ongoing random audits will occur to ensure compliance.
Ongoing, weekly random audits of 15 charts will be conducted by the Nurse Manager, and/or designee to ensure compliance.
The Methodone Initial Dosing Chart Audit (MIDCA) Form will be implemented and utilized by September 10, 2012. The MIDCA will track the results of information obtained audits including audit date, number, patient name, , UDS submission date, results, review with treating Physicians, COWS scores, order, administration, legibility, and findings. Results of the weekly random chart audits will be sent to the Director of Nursing and Regional Administrator for review.
When an audit indicates a deficiency of less than 100% compliance per week, a meeting with the Physician and Nurse Manager, or designee will occur within 72 hours to review the deficiency and correct as needed.
These indicators will be included in the tracking process allowing WDR Allenwood to identify patterns, individuals, and to take appropriate disciplinary actions as needed.
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715.23(e) LICENSURE Patient records
(e) Patient file records, information and documentation shall be legible, accurate, complete, written in English and maintained on standardized forms or electronically.
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Observations
Based on the review of client records, the facility failed to provide a complete client record that contained documentation that was legible and consistent with the services provided to the patient. The findings include:A review of the White Deer Run Detox Medical Progress Record, dated March 27, 2012, revealed documentation that patient # 1 had his blood pressure taken on March 27 at "2315 hours" (11:15 p.m.). This documentation is inconsistent with other record documentation as patient # 1 was reported deceased on March 27, 2012 at "0745 hours" (7:45 a.m.)Also, in the White Deer Run Detox Medical Progress Record, dated March 24, 2012, the facility recorded a CIWA assessment that did not include the time of assessment on the document.On the White Deer Run Medical/Methadone Order Sheet # 2, the time of the physician's signature attesting to his documentation was not legible.
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Plan of Correction
The nurse documenting this record was the nurse in shift at time of incident. The nurse was visibly shaken and inadvertently transposed 2300 hour vital signs on the wrong date of 3/27/2012, instead of 2300 hours on 3/26/2012. The vital signs were taken on 3/26/2012 at 2300 hours.
The Director of Nursing and Regional Administrator met with the treating Physicians on August 31, 2012 to review the standards related to legibility of documentation of chart entries, and ongoing compliance.
Accuracy and legibility of documentation is included as part of the ongoing weekly random chart Audits as per the Methodone Initial Dosing Audit (MIDCA) Policy and form.
When an audit indicates a deficiency score of less than 100% compliance per week, a meeting with the Physician and Nurse Manager, or designee will occur within 72 hours to review the deficiency and correct as needed.
These indicators will be included in the tracking process allowing WDR Allenwood to identify patterns, individuals, and to take appropriate disciplinary actions
Accuracy and legibility of documentation is included as part of the ongoing weekly random chart Audits as per the Methodone Initial Dosing Audit (MIDCA) Policy and form.
Addendum:
As a part of our immediate review of the incident and record WDR Allenwood identified the error and took proper steps/actions which included notifying the DOH licensing body and meeting with the staff involved. It was discussed with staff the need for accurate charting at all times including during critical events. Supervision note was conducted on the nurse mentioned.
Quarterly in-services/nurse meetings will be conducted by the nurse manager. This will include case conferences and charting examples. Any staff that shows noncompliance with the requirements for proper and timely documentation shall receive employee improvement session and up to termination. |
715.26(a) LICENSURE Security
(a) A narcotic treatment program shall meet the security standards for the distribution and storage of controlled substances as required by Federal regulations, including 21 CFR 1301.72 and 1301.74 (relating to physical security controls; and other security controls) and State statutes and regulations.
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Observations
Based on a review of the patient record and discussion with facility staff, the facility failed to provide secure storage of all controlled substances within the facility.The findings include:A review of the patient record revealed that there were reports that the patient had medications in his possession that were not provided by the facility. Documentation in the patient record indicated the patient was questioned and a patient and property search was conducted to address the concern. The medications were not found. According to facility staff, a coroner's report for the patient indicated that he had overdosed on a medication that had not been prescribed during the patient's treatment at the facility. Said disclosure confirmed that the patient did have possession of medication that had not been provided to him by facility staff.
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Plan of Correction
Client Search Guidelines revised/enhanced and implemented.
Clients admitting to WDR Allenwood sign the Consent for Treatment and Patient Orientation Form which includes consent for body search and search of personal belongings at the time of admission. Clients agree by signing such documents they understand throughout treatment staff may deem it necessary to inspect person, possessions, room search. It is imperative staff communicates such and they ensure the client understands the agreement. Clients shall always be afforded privacy during a body search.
Any suspicion behavior should be immediately communicated to the nursing staff. The nursing staff will determine if further evaluation and/or examination are needed including up to cavity search (only with consent of client). A UDS will be required. In the event a client refuses the case shall be referred to the Regional Administrator to determine next steps including up to Administrative Discharge.
All staff escorting, assisting with and/or performing searches and nursing staff will be been trained on the new client search guidelines by 09/21/2012.
Client Search Observation Checklist developed and implemented. The competency based tool allows supervisors to directly obverse/monitor staff performing searches.
Based on direct observation, any staff requiring additional training or supervision shall receive such training prior to assisting in additional searches and up to employee improvement sessions.
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