INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on April 03, 2017 by staff from the Division of Accountability and Program Improvement. Based on the findings of the investigation, Kensington Hospital Outpatient Treatment Program was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
|
Observations
A review of facility's Patient Safety Event Reports was conducted on April 3, 2017 and the facility was found in non-compliance for failure to submit a written unusual incident report regarding a medication error to the Department within 3 business days of the incident that occurred on March 15, 2017.
|
Plan of Correction
The Chief Nursing Officer will review and re-educate the Nursing Staff on the Unusual Event Reporting Policy with the Nursing Staff. The Director of Behavioral Health Services will also review and re-educate the Behavioral clinical staff on this topic. Both staff will be re-educated by 7/31/17. |
715.17(c)(7) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(7) Drug reactions and medication errors. A narcotic treatment program shall report any adverse drug reaction or medication error to a narcotic treatment physician immediately and initiate corrective action. The narcotic treatment program shall record the reaction or error in the drug administration record and the clinical chart, and shall inform each person who is authorized to administer medication or supervise self-medication of the reaction or error.
|
Observations
On March 15, 2017, the facility's LPN poured a 60 mg dose of methadone for patient, DC. The patient at the dosing window was FP. Patient FP ingested the 60 mg dose. Patient FB was treated at Einstein Medical Center Elkins Park's Emergency Department on March 15, 2017 from 1:31 PM until approximately 2:34 PM for a narcotic overdose.On April 3, 2017, DDAP's Program Representative Supervisor reviewed a Counseling / Corrective Discipline Form dated March 21, 2017. According to the documentation, the LPN failed to follow the facility's policy and procedure of completing a Confidential Patient Safety form following a near-miss medication error. However, it was not a near-miss but rather, the LPN failed to notify the narcotic treatment physician that a medication error occurred as Patient FB ingested 60 mg dose of methadone instead of her prescribed dose of 15 mg.
|
Plan of Correction
The Chief Nursing Officer will review the policy and re-educate the Nursing staff on the Medication Error policy and procedure. In the event of a Medication Error, the policy is to inform the physician and appropriate staff immediately when a medication error occurs. The Director of Behavioral Health Services will also re-educate the clinical staff regarding the policy and its importance. Both education will be held by 7/31/17. |