Observations
Based on a review of a patient record, the facility failed to document that the narcotic treatment physician determined the patient's initial and subsequent dose and schedule.
The findings include:
One patient record was reviewed during an onsite complaint investigation. The narcotic treatment physician must determine the patient's initial and subsequent dose and schedule in all patient records. The physician did not determine the patient's subsequent dose in patient record #1.
Patient #1 was admitted on December 12, 2014. The patient participated in a case conference to review his dose on March 11, 2015. The patient, physician assistant and counselor were present at the conference. As a result of the conference, it was determined that patient #1 was not eligible for a dose increase. The reasons why he was not eligible were not documented. The physician did not determine whether or not the patient was eligible for a dose increase as he was not a participant in the case conference and there was no documentation that the recommendations/results were presented to him for review.
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Plan of Correction
A policy change has been implemented. A patient requesting a dosage adjustment, other than the semi-annual dosage review, will complete a patient request form with his counselor. The form will be immediately given to the Nursing Supervisor. She will schedule the patient to see the Medical Director the next day. The Medical Director will meet with each patient and assess his request. The Medical Director will document any change in dosage in the patient chart. If the request is not granted, the Medical Director will document the rationale. |