Death of Patient

The review of the incident report log disclosed several instances of pharmaceutical mishaps. Some examples are: Wrong medications were sent home with the patient • Inventory disclosed missing or expired medications • Unauthorized person was granted access to the pharmacy room • Medication administered at the wrong time • Medication transcribed with the wrong dispensing frequency • Medication ordered but not transcribed or dispensed • Doctor transcribed medication to the wrong patient chart • ETS/ITF Arlington Campus

ETS/ITF Arlington Campus is inadequate: The average patient load of 36-42 patients per day at ETS exceeds • the 20 patients per day capacity the facility was designed to serve Fire safety requires external doors to remain unlocked allowing • patients held involuntarily the opportunity to leave the facility There are not enough interview rooms for the current patient load • Nurses' stations are cramped • Medical equipment is antiquated • Computer systems are several generations behind current • standards The lack of wireless communication within the facility requires • manual charting No connectivity to RCRMC main campus servers prevents the consolidation of patient records compounding the opportunity for charting errors The quagmire of EDA and the Office of Statewide Hospital Planning and Development (OSHPD) policies hinder any efforts to repair the facility. ETS/ITF Policies and Procedure No. 15.1 – Death of Patient

Policy No.15.1 describes procedures to be followed upon the death of a patient. The policy as written is not clear. Section 1 of Policy No. 15.1 prioritizes internal staff notification without suggesting that "911" be called to assess the patient. Section 1-c indicates a call to the Coroner/Public Administration be made "when appropriate," while Section 1-d indicates that the Coroner must always be notified. Section 2 requires staff to call for an ambulance to transport the patient to an emergency room for pronouncing of death, but Section 1-d indicates that the Coroner's office will pick up the body. Section 3 requires a call to OneLegacy, an organ transplant facilitator, without regard to patient or family desires (see Attachment #1). Policy No. 12.1 Levels of Observation This policy is dated "3/12." The policy is incomplete, consisting of pages 4. "1 of 5," "3 of 5" and "5 of 5" (see Attachment #2). Policy No. 20.1

"1 of 5," "3 of 5" and "5 of 5" (see Attachment #2). Policy No. 20.1

There are two policies numbered No. 20.1 One is dated "3/12" and titled "Therapeutic Groups (Process)" superseding Policy No. N8.03. This policy contains page "1 of 2," but is missing. The second policy has a revision date of "6/7/2013" and titled "EMERGENCY TREATMENT SERVICES (ETS) / INPATIENT TREATMENT FACILITY (ITF) DISCHARGE PROCEDURE" superseding Policy No. N12.05 (see Attachments #3 and #4).