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Lax Prescription Drug Controls Found at Santa Barbara County Psychiatric Hospital

In response to federal audit, officials beef up monitoring and accountability for drug storage

[Noozhawk’s note: Second in a series on a federal audit of the Santa Barbara County Psychiatric Health Facility.]

A recent federal audit that inspected Santa Barbara County’s Psychiatric Health Facility found that drugs routinely went “missing” at the 16-bed psychiatric hospital, with little oversight from those in charge.

The facility at 315 Camino Del Remedio was inspected by officials from the Centers for Medicare & Medicaid Services, the federal oversight body for the hospital, as well as the state Department of Public Health.

                                    Day One: Audit Highlights Deficiencies |

In a previous article, Noozhawk outlined the general concerns raised by the federal audit, which was conducted in January and resulted in 142 pages of complaints. Officials at the facility say they have since addressed the auditors’ concerns and note that the hospital has been approved for relicensing.

One of the areas of federal concern was a lack of monitoring of the Psychiatric Health Facility’s drug storage area, which was inspected and includes a list of controlled and noncontrolled drugs, as well as nonprescription drugs.

According to state and federal law, abuses and losses of controlled substances must be reported. The report details several incidents, including one in which hospital staff failed to document a lost Darvocet tablet, a pain reliever that was banned by the Food and Drug Administration in November because of cardiac side effects.

A Vicodin tablet also was found to be missing, and the facility had concluded that the tablet was lost as a result of “overcrowding” in the storage area and because medications were being stored inside large bubble packs. Interviews with the nursing staff revealed that the facility has a difficult time with controlled drugs falling out of the backs of the narcotic bubble packs “for a while,” the report said.

Nursing staff would put these tablets back into the bubble packs and reseal them with tape, the report said.

“The use of the tape to reseal the bubble packs did not conform with standards of professional practice,” the report noted.

“Facility staff also indicated that the loss of narcotics from this supply (the narcotic cabinet) had occurred with regular frequency,“ the report stated.

Review of the hospital’s reports didn’t reveal any trends with the facility’s loss of controlled substances, and the facility’s monthly pharmacy consultant report did not identify any concerns about the facility’s loss of controlled substances. Among the changes the facility has implemented are monitored, twice-daily drug inventory counts and a requirement that any discrepancies must be resolved immediately.

Inspection of the facility’s drug supply found expired drugs among the inventory, as well. The ability to access the drugs easily was also an issue.

“Facility staff indicated that anyone who had access to this drug supply could walk out of the building and go home with pockets full of these medications and no one would miss them because they were not being monitored,” the report concluded.

In the plan of correction, officials with the county Department of Alcohol, Drug and Mental Health Services maintain that the number of medications kept on site has since been reduced significantly. More detailed logs have also been put in place.

The length of time it takes to fill a prescription and deliver it to patients is also a problem area, the report concluded. PharMerica, the Louisville, Ky.-based pharmacy services company with which ADMHS contracts, transports the drugs from its Ventura facility and delivery of patient medications can take up to four hours, after the orders have been faxed from the hospital.

By the time the medications have arrived, almost 90 percent of the patients have been discharged and have left the facility without medications. The report also states that nurses were dispensing medications outside of their scope of practice.

Noozhawk talked with Dr. Edwin Feliciano, ADMHS’ medical director, about the changes that officials have made since the audit.

Feliciano said the facility has switched the containers the medications are kept in and has assigned an employee the task of counting — and accounting for — all controlled substances at the end of a shift. He said the department is also mulling whether to place the medications in a locked plastic case, which tells the number and the dose, and the pharmacy contractor will give a report to make sure the records match up.

When asked why the Pharmacy and Therapeutics Committee was not reviewing what was happening with the facility’s drugs, Feliciano did not answer directly. He did say that auditors recommended that the department establish oversight bodies specific to the Psychiatric Health Facility, instead of just overseeing the entire organization. Now, the PHF unit has its own Pharmacy and Therapeutics Committee to oversee operations.

Feliciano said he thinks the entire process has improved data tracking and collection.

“One thing that’s a positive of the process is now we have very clear guidelines,” he said. “I think that’s going to help maintain an eye on those items where they found a deficiency.”

                                    Day One: Audit Highlights Deficiencies |

Noozhawk staff writer Lara Cooper can be reached at .(JavaScript must be enabled to view this email address). Follow Noozhawk on Twitter: @noozhawk or @NoozhawkNews. Become a fan of Noozhawk on Facebook.

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