Unity Psychiatric Care-Columbia

“PHARMACY DRUG RECORDS CFR(s): 482.25(a)(3) Current and accurate records must be kept of the receipt and distribution of all scheduled drugs. This Standard is not met as evidenced by: 49575 Based on review of the facility’s policies/procedures; pharmacy policies/procedures, narcotic control records, medical records, observations, and interviews, the psychiatric hospital failed to keep current and accurate records of the receipt and distribution of all scheduled drugs. The findings included: Review of the psychiatric hospital’s “Medication Administration” policy with a revision date of 6/2025 revealed “... Wasted controlled medications shall be witnessed and cosigned... Medications shall never be borrowed from one patient’s container for another patient...” Review of the psychiatric hospital’s “Narcotics” policy revealed, “... Purpose: To monitor narcotic administration and ensure accountability for all narcotics/controlled substances. Policy: All controlled substances shall be counted at the change of each shift. The amount/number of controlled substances on hand shall be listed on the Medication Control Records and reconciled on the Narcotic Control Record... Procedure: One (1) licensed nurse from the off-going shift and one (1) licensed nurse from the on-coming shift must count and sign the Narcotic Control Record in front of the narcotic book. The off-going nurse shall write and observe counting; the counting nurse shall count each shift... The oncoming nurse shall sign his/her name on the control record. The off-going nurse shall sign his/her name on the control record... Nurse Management shall hold staff nurses accountable for preventing the loss of controlled substances and for the completion of the form prior to the off-going nursing staff reporting off duty...” Review of the psychaitric hospital’s “Disposal of Medications” policy with a revision date of 06/2025 revealed, “... 1. All unused controlled substances shall be destroyed on site by pharmacy and a member of the nursing staff. 2. Documentation of controlled substances destroyed shall be logged with the date, quantity, and type of medication. The logs shall be maintained in the Nurse Manager’s office...” Review of the psychiatric hospital’s “Controlled Substance Emergency Medication Kits” policy with a revision date of 7/2025 revealed, “...In an effort to increase the availability of controlled substance items to meet patients’ needs in [named Psychiatric Hospical] , [named pharmacy] shall provide each facility a controlled substance Emergency Kit to be utilized for EMERGENY SITUATIONS. Definitions... ‘Emergency’ An emergency for this purpose shall be defined as to meet the IMMEDIATE THERAPEUTIC NEED OF THE PATIENT. This includes but is not limited to new orders for patients, new admissions or if directed by nurse management or pharmacy. Procedure: If a prescribing agent deems it necessary for a patient to have a controlled substance and issues an electronic prescription and if a nurse deems an EMERGENCY situation to open the Emergency Kit, then: 1. Provide a list of available medications to prescriber for proper order. 2. Notify Nurse Management for approval. 3. Contact [named pharmacy] (After hours, utilize on-call number...). A pharmacy representative shall take the name of the nurse, nurse manager notified, patient’s name and medication, quantity to be removed and shall issue the access code for the kit. NOTE: ONCE THE ACCESS CODE IS ISSUED TO THE NURSE THEN THAT NURSE SHALL BE RESPONSIBLE FOR THE CONTENTS OF THE BOX UNTIL EITHER BOX IS REPLACED OR NURSE IS OFF-SHIFT AND A NEW NURSE IS PROVIDED WITH CODE BY PHARMACY... When the nurse opens the ER Box and retrieves medication, two (2) nurses must sign the [named pharmacy] Emergency Kit Removal Form, verifying contents and quantities of the box...” The policy did not address controlled substance medication counts/documentation by two nurses at the beginning and end of each shift. Review of psychaitric hospital’s “Narcotic Control Record” dated 07/23/2025 - 08/12/2025 revealed illegible and/or incomplete signatures on 7/23/2025, 7/272025, and 07/28/2025. Card/count numbers and/or dates were written over and/or changed on 07/24/2025, 07/25/2025, 07/28/2025, 07/30/025, 08/01/2025, 08/08/2025, 08/10/2025, and 08/11/2025. The Comment Section of the Narcotic Count Record lacked sufficient data to clearly determine whether the controlled substances ordered for specific patients correlated with the controlled substance count for that particular patient or for all the patients for whom controlled substances were ordered. Observations of the preparation/administration of scheduled medications on 08/11/2025, at 2:00 PM, Registered Nurse (RN) #1 stated the hydrocodone card for Patient #10 was empty. The Pharmacy had not been notified by the nurse who administered the last hydrocodone in that card that Patient 10 needed to have her scheduled hydrocodone refilled. There was no hydrocodone to administer the 2:00 PM scheduled dose. RN #1 called the pharmacy, obtained the code to open the emergency lockbox located in a locked room in the nurse’s station. RN #1 failed to follow the facility’s policy re: notification of unit manager prior to contacting the pharmacy for a code to the emergency lockbox and/or accessing medication in the emergency lockbox. RN #1 opened the emergency lockbox without a second nurse to witness and removed hydrocodone from the emergency lockbox without a second nurse present to witness and document. RN #1 violated the [named pharmacy] procedure for accessing the emergency lockbox and removing controlled substances from the emergency lockbox. Observations during medication administration on 8/11/2025, at 2:25 PM revealed Patient #10’s ordered/scheduled hydrocodone was not available. The hydrocodone medication card was empty. Patient #10’s hydrocodone was ordered to be administered 3 times daily. There was no documentation the pharmacy was notified Patient #10 needed another hydrocodone medication card. RN #10 contacted the Pharmacy via telephone at 2:32 PM on 08/11/2025 and requested the code to access the emergency lockbox containing controlled substances. That lockbox was located in a locked room within the nurse’s station. RN #10 did not contact the nurse manager prior to contacting the pharmacy to obtain the code required to access the emergency lockbox. RN #10 received that code, accessed the emergency lockbox, and withdrew a card of hydrocodone. RN #10 did not have a second nurse witness the opening of the lockbox or her withdrawal of the hydrocodone card. While setting up Patient #10’s scheduled 2:00 PM. medication, RN #10 dropped the hydrocodone tablet on the floor. RN #10 disposed of that hydrocodone tablet without another nurse witnessing. RN #10 withdrew a second hydrocodone tablet from the card of hydrocodone removed from the emergency lockbox without a second nurse witnessing that withdrawal. During that observation, RN #10 reported RN #10’s role that day was medication nurse and “RN nursing”. She stated that narcotics are counted and documented by 2 nurses on each shift. RN #1 was observed destroying/disposing of a hydrocodone tablet that she dropped on the floor without having a second nurse observe and document the destruction/disposal of the controlled substance. RN #1 was not observed to notify the DON or ADON that the hydrocodone tablet was wasted. During an interview on 8/11/2025, at 3:15 PM, the Director of Nursing (DON) reported that controlled substances are counted each shift by the nurse coming on that shift and the nurse leaving the previous shift. Those two nurses sign the controlled substance/narcotic count sheet. The count sheet must have signatures of two nurses when controlled substances are administered by a nurse. The psychiatric hospital does not have an onsite pharmacy. (named Pharmacy) provides medications for the psychaitric hospital. Each patient’s controlled substance medication card has that patient’s name on it. If the controlled substance medication count is “off”, 2 nurses must re-count the medication. If the second count is still “off”, the DON must be contacted immediately. The DON and Risk Manager would investigate and the incident would be addressed in the morning meeting. The Nurse Practitioner or Psychiatric Medical Provider writes the medication orders for each patient. Those orders are sent to the pharmacy. The ordered medications are delivered to the hospital by the pharmacy, usually on the night shift. There is a locked box containing emergency medication, including controlled substances, located in a locked room within the nurse’s station. That lockbox is supplied by the pharmacy. When the pharmacy brings the lockbox, or medication to be placed in the lockbox, to the hospital, the pharmacist and a psychaitric hospital nurse sign the count sheet for the items in the lockbox. The purpose of the lockbox is to provide medications needed by newly admitted patients when their scheduled or as needed (PRN) medications have not yet been delivered by the pharmacy. When the pharmacy brings the lockbox containing medications to the hospital, that box has a tag on it that documents the medication counts of the medications in the lockbox. If the lockbox must be accessed for a controlled substance, 2 nurses must witness the withdrawal and document/sign the withdrawal on the controlled substance count sheet and tag on the emergency box. The pharmacy is to be immediately notified. The number of medications, sign-out sheet, and the lockbox tag must correlate. Both nurses must sign off and a new zip tag with the new number of controlled substances is then placed on the lockbox. The only time a scheduled medication should be needed from the lockbox is for a newly admitted patient. The nurse who administered the last of Patient #10’s scheduled hydrocodone should have immediately notified the pharmacy so it could be filled and delivered by the pharmacy. Two nurses must be witness and sign-off when a controlled substance is destroyed. During a telephone interview on 08/11/2025 at 3:25 PM, the ADON for the psychaitric hospital reported that if a prescribed controlled substance is not available on the unit for the patient administration, the assigned nurse notifies the Pharmacy. The Pharmacy sends “about 5 or 6” doses of that medication to the unit the patient is on. The medication administration nurse must sign for that medication when the pharmacy delivers it. If the emergency lockbox is opened to obtain controlled substance medication, two nurses must sign when the medication is removed from the lockbox. It is not typical for a unit to run out of a patient’s prescribed controlled substance medication. The unit nurse/medication nurse should notify the pharmacy when the patient begins to “run low” on their prescribed control substance medication. Two nurses must witness and document when a controlled substance medication is destroyed. During an interview on 08/12/2025 at 8:30 AM, RN #2 reported the hospital’s policy is for two nurses to count the controlled substances every shift change and document the findings on the narcotic count sheet. Any discrepancies are reported immediately to the DON. Two nurses are required to witness and document waste of controlled substances. There is a lockbox in a locked room in the nurses’ station at the psychaitric hospital. Two nurses are required to witness and document removal of controlled substances from the lockbox. During a telephone interview, on 08/12/2025 at 1:43 PM, the (named Pharmacy) Director reported the pharmacy delivers prescribed medications for the psychaitric hospital’s patients on a routine scheduled basis. He confirmed that (named Pharmacy) received a telephone call from RN #1 on 08/12/2025 reporting that Patient #10’s card of hydrocodone was empty. RN #1 received the code to open the emergency lockbox at the hospital to obtain hydrocodone for Patient #10’s scheduled 2:00 PM dose on 08/12/2025. RN #1 accessed the lockbox and withdrew the card of hydrocodone without a witness. The purpose of the lockbox is for availability of the first dose of a newly admitted patient to the psychiatric hospital. (named Pharmacy) makes medication deliveries to the hospital on Monday through Thursday. If a medication is needed stat, the psychiatric hospital sends the prescription to (named pharmacy) to be filled, and (named Pharmacy) would be able to deliver the stat medication the same day. (named Pharmacy) can deliver requested medication after-hours as well. For a nurse to open the lockbox. the nurse must obtain a code by calling (named Pharmacy). Once (named pharmacy) has been notified that the lockbox has been accessed, they send a replacement medication the following day. Medication pull slips from the lockbox and lockbox medications are compared for any discrepancy. Two nurses are supposed to witness and sign when the lockbox is opened. Any discrepancies in the controlled substances count must be reported to the chain of command at the psychiatric hospital.”

“Building Construction Type and Height CFR(s): NFPA 101 Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. This Standard is not met as evidenced by: 50784 Based on observations, the facility failed to maintain the fire rated construction of the 1-hour ceiling assembly. The building construction is NFPA type V (111). The findings include: 1. Observation on 08/12/2025 at 11:32 AM, revealed unsealed penetrations by electrical and HVAC lineset items in the 1-hour fire rated ceiling of the kitchen storage room. NFPA 101, 8.3.5.1 (2012 Edition) 2. Observation on 08/12/2025 at 11:51 AM, revealed an unsealed penetration by low voltage wiring in the 1-hour fire rated ceiling of the IT room. NFPA 101, 8.3.5.1 (2012 Edition) 3. Observation on 08/12/2025 at 12:10 PM, revealed an unsealed penetration by low voltage wiring in the 1-hour fire rated ceiling of the 100 hall Electrical room. NFPA 101, 8.3.5.1 (2012 Edition) The Maintenance Director was present when these findings were identified and they were acknowledged by the Administrator during the exit conference on 08/12/2025.”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 50784 Based on document review and interview, the facility failed to maintain the emergency lighting. The finding includes: Document review on 08/12/2025 at 10:50 AM, revealed the facility could not provide monthly or annual testing documentation for the battery backup emergency lights. Interview with the Maintenance Director revealed the facility did not keep logs documenting lighting tests. NFPA 101, 19.2.9.1 (2012 Edition) NFPA 101, 7.9.3.1.1 (2012 Edition) The Maintenance Director was present when this finding was identified and it was acknowledged by the Administrator during the exit conference on 08/12/2025.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 50784 Based on document review, the facility failed to maintain the fire alarm system. The finding includes: Document review on 08/12/2025 at 10:30 AM, revealed the facility could not provide documentation for the required 2 year smoke detector sensitivity testing. NFPA 101, 19.3.4.1 (2012 Edition) NFPA 101, 9.6.1.3 (2012 Edition) NFPA 72, 14.4.5.3.2 (2010 Edition) The Maintenance Director was present when this finding was identified and it was acknowledged by the Administrator during the exit conference on 08/12/2025.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 50784 Based on observations and interview, the facility failed to maintain the HVAC systems. The findings include: Observations on 08/12/2025 at 11:42 AM, revealed 3 ceiling HVAC openings connected above the ceiling with flexible duct that were not equipped with fire dampers in the 1 hour fire rated ceiling at the 200 hall nurses station and medication room. Interview with the Maintenance Director revealed this space had been renovated in 2024 and the ductwork added for these rooms. NFPA 101, 19.5.2.1 (2012 Edition) NFPA 101, 9.2.1 (2012 Edition) NFPA 90A, 5.3.1.2 (2012 Edition) The Maintenance Director was present when this finding was identified and it was acknowledged by the Administrator during the exit conference on 08/12/2025.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 50784 Based on document review and interview, the facility failed to maintain the emergency backup generator. The finding includes: Document review on 08/12/2025 at 10:15 AM, revealed the facility could not provide annual fuel quality testing documentation for 2023 or 2024. Interview with the Maintenance Director revealed this test had not been conducted prior to this year, but was now part of the contract. NFPA 99, 6.4.4.1.1.3 (2012 Edition) NFPA 110, 8.3.8 (2010 Edition) The Maintenance Director was present when this finding was identified and it was acknowledged by the Administrator during the exit conference on 08/12/2025.”