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George Allen Wa Pab Appeal Disciplinary Action Case File 1997

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RECEIVED
STATE OF WASHINGTON

2828 upitol Blvd.
PO BOK 40911
Olympi",. WA 98S04.{l911

JU~].a,Q8lS~;r,
fAX (360) .';3-6139

PERSONNEL APPEALS BOARD

Departmem 01 Ccrrectlons

Division of Human Resources

June 27, 1997

Elizlbeth Baker

Washington Public Employees Association
124-10thAvenueSW
Olympia. \VA 98501

RE:

George Allen v. Department of Corrections, Reduction in Salary Appeal,
Case No. RED-97-Q034

Dear Ms. Baker:
This lener is

to

acknowledge receipt of the above entitJed appe:Jl by the Personnel Appeals Board

on June 16, 1997.
Sinc~rely,

Executive Secretary
KJL:unp
cc:
George Allen
Linda A. Dalton, AAG
Jennie Adkins, DOC

093~
.t:\lmp\nCW3ppl\~len

,"

•

JUri f 6 1997
~..sHING'ltlN

STATE ~ AP!lE:ALS ECABD
.
PH:

2828 capi.t:oI Eoutevard
P.o. Box 40911

FAX:

Olympia, WA 98504-0911

SCAN 321-148i
(206) 586-1481
. (206) 753-0139

This fQl:lll will help you. p:c:ovide necessary iDfomation to the Pex:sonnel Aoceals Boani when
you file an ~ You ~.!JQt. .reqt.ti..red.1:o use this fOl::ll; ~ver, ~ ~be filed
i.:1 acconiance with the requ:U:ement:s set for-..n :in C1apt:er 358-20 WAC.

If the space on the fom is insufficient or if you wish to pmvide additioca.l infoaation,
you may a:t:tacl1 additional pages.
. .
.

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SIGN ON !lAG: 2

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The Board. must be r.ctified of any change i:1 representaticn.
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sepa-."CI.tion- - -~e or S-~te c.:..v'..l Serlice Law Violaticn
(c~ete ?A."l\T!V. of t."::!.s fc=:t)
Reduction in Force
(ccmplete ?~!V. of t."::!.s fo::l.)

Allocation (pcsi.t:.on classi.:Eicat::.cn)
(cc::nplete ?.M!!' V. of this fo::l.)
DeclaratcJ:Y :luli.nq (see WAC 358-20-050)

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RECEIVED

..

APR 031998
1828 ~ilol Blvd.
artment Of coff8ClionS
PO Boll 40911
__ ~on of Human ResoUfCl!S
Olympia. WA 98SlM-G"J1T

VOICE (360) 586-1481

fAX (360) 7SJ.al39

E-MAIL

in(o-pah~.sute.w~.us

STATE OF WASHINGTON

PERSONNEL APPEALS BOARD
HOME PAGE www.wa.gov/pab

March 31, 1998

.

STATEJlfENT OF RESULTS OF PRE-HEARING CONFERENCE

George Allen v. Deparnnent of Corrections
Case No.: RED-97-o034 (Reduction in Salary)

A pre-hearing conference was held in the above-captioned matter at 2:00 PM on March
31, 1998 by telephone conference call. Participants mthe conference were:
Mark S. Lyon, for the Appellant;
Elizabeth Delay Brown, for the Deparnnent of Corrections; and
Don Bennett, for the Personnel Appeals Board.
This statement is issued to record the agreements made by the parties' representatives
during the pre·hearing conference and to control the subsequent course of the proceeding.
The parties stipulated to the following matters:

1. Discovery is to be completed by August 28, 1998. Requests for discovery must be
served with sufficient time for responses to be completed by August 28, 1998.
2. Witness lists and exhibit lists are to be exchanged on or before September 16, 1998.
The parties reserve the right to supplement the lists.
3. Pre-hearing briefs, if prepared at the discretion of the parties, will be filed on or
before September 25, 1998.
4. The hearing in this matter will be held on September 29, 1998 beginning at 9:00 AM
in the Personnel Appeals Board Hearing Room, located at 2828 Capitol Boulevard;
Olympia, Washington.
.
S. lbis appeal will be assigned to a mediator by the Executive Secretary so that the
parties may meet on a mutually agreed date and engage in a good faith attempt to
negotiate a resolution of the appeal pursuant to WAC 358·30-024.

0991

\
statement of Results ofPt~hearing
March 31, 1998
Page 2

The pre-hearing conference was recessed until 9:30 AM on September 25, 1998. At that
time, the Executive Secretary or his designee will initiate a conference call with the
parties' representatives to discuss possible stipulations on witnesses, exhibits, and the
issue to be presented for detemination by the Personnel Appeals Board.
The parties shall arrive at the hearing location thirty (30) minutes before the hearing time
for the purpose of exchanging copies of exhibits and, if possible, stipulating to admission
ofexhibits. The parties shall bring six (6) copies of the pre-marked exhibits which they'
intend to offer into evidence.
Any objections or corrections must be filed with the Executive Secretary within 20
days of the date of this statement and shall, at the same time, be served upon each of
the participants named above.. This statement becomes part of the official record of
the proceedings, and the stipulations will be binding on the parties, unless this
statement is modified for good cause.

Dated: ~-"> J-

98""

PERSONNEL APPEALS BOARD

BY~~,~-

»<Q--

- DON BENNETT
Executive Secretary

0992

-

'.

RECEI"

•
21128 ~pitol 81vd.
PO So• .-0911
Olympia. Witt. 98504-l)911

[ c:

:D

JUN {} 0 1998
Oeparnnent or (;vrr:;:":tioroS
Qivisicn of Human Reso:.::cos

STATE OF WASHINGTON

tt

ff '!u;7e.

1/(Itt~CE (360) 5~1.q1

FAX 1360) 753.0139

E~\tAll inro-pab~pab.mte.wa.U$

PERSONNEL APPEALS BOARD
HOME PAGE www.wa.gov/pab

June 5, 1998
Elizabeth Delay Brown
Assistant Attorney General
P.O. Box 40145
Olympia, WA 98504-0145
MarkS. Lyon
WPEA
P.O. Box 7159
Olympia, WA 98507
RE:

George Allen v. Department of Corrections, Reduction in Salary appeal,
Case No.: RED-97-0034

Dear Ms. Brown and Mr. Newberry:
This letter is to advise you that this case has been assigned to Michael Mallinger. He is a
mediator contracted by the Personnel Appeals Board. Mr. Mallinger will be contacting you for
the purpose of scheduling a mutually agreeable date and time for a mediation. We appreciate
your cooperation in scheduling mediation as soon as possible or the file may be returned to our
office to set a date for hearing.
Mediation is an opportunity to bring the panies together to attempt a settlement of the issues on
appeal without the need for a hearing. If settlement efforts are unsuccessful, the meeting will
move into the prehearing phase and the panies will select a hearing date, attempt to narrow the
scope of the issues to be presented to the board, discuss witness and exhibit lists, and possible
stipulations between the parties.
If you have any questions, please contact me.
Sincerely,

~_\~
Don Bennen
Executive Secretary
DB:py
cc:
George Allen
Jennie Adkins
F:P:wIettcJMedialOrsllc:acr 10 patties

-0993

·.

.RECEIVErAPR 03 1998
. CO(t8CtiOOs

Department 01 Resources
DNision of Human

2

BEFORE THE PERSONNEL APPEALS BOARD

3

STATE OF WASHINGTON

4

5

)

~ NOTICE OF SCHEDUlING

Appellant,

6
7

) Case No. RED-97-0034

GEORGE ALLEN,

v.
DEPARTMENT OF CORRECTIONS,

8

ResPondent.
9

10
11

)
)
)
)
)

-------------)
Notice is hereby given of scheduling the hearing on the appeal before the Personnel Appeals Board.
The hearing will be held in the Personnel Appe:l1s B"oard Hearing Room, 2828 Capitol Boulevard,
Olympia, Washington, on Tuesday, September 29,1998, beginning at 9 a.m.

12
13

14

The parties shall arrive at the hearing location thirty (30) minutes before the hearing time for the
purpose of exchanging copies of, and when possible, stipulating to exhibits. The parties shall bring
sL"{ (6) copies of the premarked exhibits which they intend to offer into evidence. Whenever
possible, the parties should exchange witness lists prior to the day set for the hearing.

IS
16

If the services of an interpreter are needed, notify Personnel Appeals Board staff at least two weeks
prior to the hearing. The hearing site is barrier free and accessible to the disabled.

17

18

DATED this 1st day of April, 1998.

19

WASHINGTON STATE PERSONNEL APPEALS BOARD

20
21
22

Teresa Parsons, Hearings Coordinator
(360) 664-0479

23

cc:
2S
26

George Allen, Appellant
Mark S. Lyon. Attorney
Cindy Nabbefeld. WPEA
Elizabeth Delay Brown. AAG
Jennie Adkins, DOC

0994
Personnel Appols Bocud
2828 Capitol Boulevard
Olympia. Washington 98504

Cc-·WCGV·

RECEIVo::"D
1\"~
,.,U'.:l

2828 Capitol Blvd.
PO Box 40911
Olympia. WA 98504-0911

.:')

.'-rUY-ICJ/~

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VOICE (360) 586-1481
FAX(360)7S3-0139
. E·MAll info-pab@pab.stale.wa.us

STATE OF WASHINGTON

PERSONNEL APPEALS BOARD
HOME PAGE www.wa.gov/pab

August 25, 1998

MarkS. Lyon
WPEA
PO Box 7159
Olympia, WA 98507
RE:

George Allen v. Deparnnent of Corrections, Rec;.lction in Salary Appeal,
Case No. RED-97-0034

Dear Nlr. Lyon:
Enclosed is a copy of the order of the Personnel Appeals Board in the above-referenced matter.
The order was entered by the Board on August 25, 1998.
Sincerely,

Don Bennett
Executive Secretary
DB:k:w
Enclosure
cc:

George Allen, Appellant
Elizabeth Delay Brown, AAG
Jennie Adkins, DOC
Cindy Nabbefeld. WPEA

0995
.~{

...

. RECEiVE
•

AUG 24 1998

De~.;r., C\ " .~. ':~M'::::'
"'~~,,:.:r::v

Divisicr: vi :-!'Jmar.

1

BEFORE THE PERSONNEL APPEALS BOARD

2

STATE OF WASHINGTON

3
4

)

GEORGE ALLEN
Appel1an~

5
6

7

v.
DEPARTI1ENT OF CORRECTIONS,

8

9
10

)

Respondent.

)
)

Case No. RED-97-0034

)

MOTION AND ORDER
OF DISMISS.A.!.

)
)
)
)
)

)

The Appellant hereby notifies the Personnel Appeals Board that he wishes to

11

withdraw the above-entitled appeal.
12
13

DATED this 20th day of Au~t. 199~

14
15

MARK S. LYON, WSBA # 12WPEA General Counsel /,
Attorney for the Appellanl/

16

!/

17

This matter came regularly before the Personnel Appeals Board on the
18
19

consideration of the request of the Appellant to withdraw his appeal. The Board having

20

reviewed the files and records herein, being fully advised in the premises, and it

21

appearing to the Board that the Appellant has requested to withdraw his appeal, now

22

enters the following:

23
24
25

0996

26
27

MOTION AND ORDER
OF DISMISSAL· I

MARKS. lYON
WPEA Cener.al Cow-I
Washington Public Emplo~ees Association
Mailing Address: P.O. Box 7tS9. Olympia. WA 9850i
l.oc311on: tolO Peteival Sf. N.W.. OI~mpi4
Telephone: (360) 943-1121

•

1

2
3
4

ORDER
NOW, THEREFORE, IT IS HEREBY ORDERED that the Appellant's request to
withdraw his appeal is granted and the appeal is dismissed

5
6

DATEDthisa29'- day of

a~J

,19S!?

7

WASHINGTON STATE PERSONNEL APPEALS BOARD
8
9

10
11
12

13
14

15
16

17
18

19

20
21

22
23
24
25

0997

26

27

MOTION AND ORDER
OF DISMISSAL· 2

MARKS. LYON
\'/PEA Cl9leral CcnuIseI

Washington Public Employees Association
Mailing Address: P.O. Box i159. Olympi4. WA 0)8501
Location: 140 Percival 51. N.W•• Olympi.a
Tefephone: 13601 943-11 21

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60 days end 5/21/97
10% for 6 months

DRAFT

CATE

PERSONAL SERVICE
CONFIDENTIAL

Mr. Allen: .
This is official notification that you will be reduced in pay within your present class of _
.Registered Nurse 2 with the Department of Corrections (COC), Washington Corrections
Center (WCC) from Range 45N, Step P, $3690 per month to Range 45N. Step L.
$3345 per month effective (DATE) through (DATE).
This disciplinary action is taken pursuant to the authority of the Civil Service Law of
Washington State, Chapter 41.06 Revised Code of Washington (RCW), and the Merit
System Rules (MSR). Title 356 Washington Administrative Code (WAC). WAC 356-34010 (1) (a) Neglect of dUty. (i) Willful violation of the published employing agency or
department of personnel rules or regulations and WAC 356-34-020 Reduction in salary-Cemotion-Procedure.
Specifically, you neglected your~u
and willfully violated department policy on January
060 mg. tablets of MS Contin
26, 1997, when you gave Inmat
(morphine sulfate) instead of the prescn ed two 30 mg. tablets of Percocet This error
eventually led to the transport of the inmate to a 10caJ~p~itionally. on this
same date, you made an unauthorized visit to Inmat~t St Peter Hospital
in Olympia, Washington. You did not inform your supervisor or the shift commalJder
that you were going to make this visit and circumvented the security process at St
Peter Hospital to gain access to the inmate's hospital room. These incidents are
described in detail in the Employee Conduct Report (ECR) completed on March 21,
1997, which is attached hereto and incorporated herein (Attachment 1).
By your actions, you willfully violated departmental expectations and neglected your
duty by failing to meet these expectations that are outlined in the DOC Employee
Handbook. which states in part
"DEPARTMENT EXPECTATIONS
As a representative of the Department of Corrections, you will be expected to:

.

Remain constantly alert in all situations;

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George Allen
DATE
Page 2

You are not allowed to:

*

Engage in personal relationships with offenders, their family
members, or dose personal associates;-

Further, your actions constitute neglect of duty and willful violation of DOC Policy

854.075, Employee Relationships with Department of Corrections Offenders, which
states in part

"2.
•

Association with Offenders: Association with DOC offenders is to be
avoided in the interest of professional unbiased service. Unofficial .
contacts with known offenders under the jurisdiction of DOC are to be
reported by employees to their supervisors on form DOC 3-39(X). This
does not indude casual, unintentional and unsubstantive contacts.
Personal communications and/or relationships between employees and
offenders are not appropriate and are prohibi~ed."

On October 11, 1993, you signed an Acknowledgement of Receipt of DOC Employee
Handbook, which states:
"I acknowledge receipt of the June 1993 Washington State Department of
Corrections Employee Handbook and agree to become familiar with and have a
thorough knowledge and understanding of the contents."
On May 7,1990, in reference to DOC Policy 854.075, you acknowledged that you have
"read, discussed, and understand the contents of this Policy Directive." Copies of the
DOC Employee Handbook, pages 2 and 3, DOC Policy 854.075 and Acknowledgement·
of Receipt of DOC Employee Handbook are attached hereto and incorporated herein
(Attachments 2 through 4, respectively).
When we met on March 21, 1997, to discuss the inci~~~rredon January 26.
1997, you readily admitted that you had given Inmate~e wrong
medication. You stated that you were experiencing stress and picked up the MS Contin
instead of the Percocel You explained that the two medications are stored dose
together and packaged similarty but at the time, you thought you had the correct
medication. It was not until the narcotics were being counted that it was discovered
that two tablets of 60 mg. MS Contin were missing.
As medical professional, you are expected and have a duty to be alert to details while
dispensing medications. This is extremely important to minimize the possibility of
making errors or causing a serious life-threatening incident Your inattention in
retrieving and administering the correct medication to the inmate could have resulted in
serious medical consequences for the inmate. You not only gave the inmate the wrong

1001

George Allen
DATE
Page 3
medications, but you also gave him twice as much medication as prescribed, i.e. 120
mg. instead of 60 mg. When I asked you what could be the worst thing that could
happen from making a medication error such as the one that you made, you indicated
that the inmate could have died. Fortunately, this did not occur in this situation but
there was an emergent need to transfer the inmate to a local hospital for doser
observation. Your lack of attention in the perfonnance of your duty to propeny
. dispense medications constitutes a neglect of duty.
In discussing your unauthorized visit to Inmat~you stated while on your .
way home, you decided to stop by and visit the inmate because you had cared for him
whOe he was in the infirmary at wee. You knew he was dying and wanted to know
how he was.doing. However, you did not infonn your supervisor or the shift
.
commander that you w~.~ to visit the inmate. When you anived at Sl Peter
Hospital where Inmat~as hospitalized, you did not gain clearance from
the receptionist or the ward staff to proceed to the inmate's hospital room. At no time, .
did you identify yourself as a wee employee. Ho~pital staff alerted the officer on duty
that an unauthorized and unidentified visitor was on their way to the room. The officer
responded to this call by ensuring the inmate was secure. When you anived at the
room, the officer did recognize you as a nurse from wee. Shortly thereafter, a hospital
security officer arrived at the inmate's room, questioned who you were and explained
that you had failed to comply with hospital security procedures. Your actions caused
undue alarm for hospital security and the officer on dut¥ as well as disrupting the care
of the inmate. You acted in an irresponsible and unprofessional manner thereby
neglecting your duty.
Additionally your visit to Inmat~t Sl Peter Hospital was an unauthorized
and intentional personal commumcation with an offender. This was inappropriate and
prohibited behavior on your part. Employees have a responsibility and are required by
policy to maintain an unbiased and professional relationship with offenders at all times.
By your actions, you have willfully violated agency policy and neglected your duty to
comply with the policy.
I

You signed acknowledgements stating that you had received and understood DOC
Policy 854.075 and the DOC Employee Handbook. Your knowledge of department
policy and expectations demonstrates the willfulness of your acts of misconduct.
Your actions on January 26, 1997, cause me to have serious concerns about your
judgment and your ability to properly and effectively perform your duties as a registered
nurse. Your medication error on this date was not the first error that you have made.
You admitted that you have made four or five medication errors since you began work
here seven years ago. You went on to say that you never tried to hide these errors and
reported them immediately. You stated procedural changes have been made to help
reduce the possibility of making medication errors. Nonetheless, your inattention in
properly dispensing medications is a liability for the facility and could place an inmate in
a life or death situation.

1002

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•
George Allen
DATE
Page 4
Your failure to comply with porleY and refrain from personal and unprofessional
communications with an offender causes me to have doubts that in the future you will
act appropriately. Improper communications with inmates could potentially lead to
safety and security issues. Given the seriousness and nature of your miscondu~ as
well as the obvious lack of judgment on your part, I believe the disciplinary action
desaibed in the first paragraph is appropriate and warranted. You are hereby
forewarned that future performance problems/errors/omissions may lead to further
corrective/disciplinary action, up to and including dismissal.
You have the right to appeal this action under the provisions of WAC 358-20-010 and
WAC 358-2().()40, or to me a grievance in acccrdance with Article 10 of the Collective
Bargaining Agreement between the Department of Corrections and the Public
.
Employees Association. If you me an appeal, it must be med in writing at the office of
the Personnel Appeals Board, 2828 Capitol Boulevard, Olympia, WA 98504, within ~O
•days after the effective date stated in the first paragraph of this letter.

,
The Merit System Rules, WACs, Department of Corrections policies and Collective
Bargaining Agreement are ava~able for your review upon request

Phil Stanley
Superintendent
PS:sma
Attachments (4)

cc:

Jennie Adkins, Director, Division of Human Resources
Eldon Vail, Command Manager, Division of Prisons
Unda Dalton, Senior Assistant Attorney General
Robert Turk, Area Personnel Manager
Shalice Ando, Personnel Officer
Personnel File

1003

r

•
EMPLOYEE PROFILE

DEPARlMENT OF CORREcnONS

Page One of Two
Name

OassHIcatJan

ALLEN, George

Registered Nurse 2
Amount

Status

CtJIJent RangelStep

. Permanent

Range 45N, Step P

PROPOS£DAC110N:

DAlES

From

6 /

_0

PID Date (Affects?)

$3690.00/month

11-1-97 (Yes)

10% for 6 months
1 / 97

Ta

RANGElSTEP From 45N/P

12

/

Ta

1 / 97
45N/L

No. of Months
($)

[§:J

3345.00Imo

TOTAL LOSS
($)

2070.00

A. PERSONNEUPAY ACT10NS lInfgrmatjgn gbtained fJpm pea Qgcuments): Original date of hire. dat8(S) of agencylinstitution
transfer(s). dale(s) af promotion(s). dale(s) of pay change(s) due to dlscipDnary action(s). etc. Ust only information which is re/evan'

the aetJon being ptOpOSed.
EFFECTlVE DATE

5-7-90

1

TYPE OF AcnON

DISCtPUNARY?

DAle OF HIRE

No

2

I,

;

--J

I
I
..____J_ - - I

3

I

4

!

6

'0

o

"

I

.
Above section continued on Page Twa

B. EMPLOYEE PERFORMANCE EVALUATIONS
OATES (MoIYr)
From
To

Ratings *

Far Exceeds

Ratlngs *
Exceeds

Ratings *

Normal

Ratings *
MinImum

RatIngs *
Falla MIn.

Type rammen.s (Note If EPE Is par

••

I
AI
A

5/95

to

5/96

A,B,C,E

0

5/94

to

5/95

A,B,C,O

E

5/93

to

5/94

A,B,C,O,E

A

5/92

to

5/93

A.B,C,O,E

A

5/91

to

5/92

C

A,B,D E

A

to

5/91
Q/QO

ABDE
A,B,E

A

5/90 to

C
C,O

9/90
0

o

of DIsciplinary La«er)

I

p

to
Above s8dion oontinued 00 Page Two

• Ust p.ro"".nt» Dimensions:

• Indlcat. Typs of EvallUtlon:

A • Accompfishment of Job Requirements
B • Job KnoWledge and Competence

P • Probatiooa'Y

C • Job RellabUIty

T • Trial
S - Special

o•

PersonalRe~tioos

E • Communicalions Skills
F • Performance as SupeMsor

A • Annual

1004

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-

-

DEPAaTMENT OF CORRECTIC:••

JYEE CONDUCT~e.~TvE

. EM.

THIS FORM TO BE USED IN COMPLIANCE WITH POLICY DIRECTIVE NO. 857.005 FEB.(;.~

;997

~'A;iH C .. _

PeRSON~~CO'(;FF'1I<TA.
ree

INSTRUCTIONS AND TIME UMITS:

1. The person making the report shall provide a clear description of the incident under "Oescription of Incident"
and. with any witness(es) or person(s) having knowledge, shalt sign in the space provided and submit to the
supervisor of the Involved employee within fourteen (14) calendar days after the date of discovery of an
emplOyee's alleged misconduct.

2. The form shall be submitted to the employee involved who shalt complete the "Employee's Statement" and
return the report to his/her supervisor within seven (7) calendar days following the date of receipt.
3. The appropriate supervisor shall review the facts of the incident. complete the "Supervisor's Report" and
submit the report to the Office Head within seven (7) calendar days following the date of receipt.
4. The Office Head or designated representative shall review and within thirty (30) calendar days following the
date of receipt determine whether misconduct has occurred. This shall be reported under "Administrative
Comments" and shared with the employee. When the supervisor and Office Head are Ihe same person, the
supervisor's ~upervisor shall complete the Administrative Comments.
EIoII'\.OYai IltYClLVEO

ORQANV.flOHAt,IlHlf

wee /

George Allen
POSifIOH

mu

Infirmarv

OAfll OF IltCIOEHf

1 J?~

ReQistered Nurse 2

IIlW€OFlHClllEHf

DAM DpM

Iq7

DESCRIPTION OF INCIDENT:

It is alleged that on January 26, 1997, that you erroneously gave a medication to
inma

otential

his

emergency transport to Mason General Hospital.
It'is further alleged that you attempted to contact inmat~~a~t

_

St. Peter Hosoital. also on January 26. 1997. without the knowledae of YOllr slioervisots.

INITIATED BY:
HAWtlIPUlASE PRINt)

Frank Barth
WlTNESS(ES):
IWoIE

-

~POSlrt<lNmu

ealth Cara Manaaer

I
I

7r
\

/J
/1/\
/lkJ 7

-.

-;1
7

P05lrt<lIl mu

~~'''URe

mu

S1GHArUlle

POS111OH

q-r~:Xl

-

DAre

2/4/97

-.......J

T

I

~

DAre
OArE

10~ACHMENT
PAGLLOF

_

{ul:

•
DATE DELIVERED TO EMPLOYEE

cJ./y!v
»

?

UtPI.OYeE'S STA1l!MEHT:

Signature 01
Employee:
SUPERVISOR'S REPORT:

DATE RECEIVED 8Y SUPERVISOR

In review of the attached documentation, and statements made by Employee George Allen, it

appears that both the incidents as alleged in the ECR have occurred as reported.
the attached

documentatio~,

it is apparent that employee Allen was

a~Jare

In revielJ

01

of appropriate

procedures regarding giving the medications and his actions did create a potential danger to
a patient. In reference to the second allegation, and review of emplovee Allen I s personnel
file, he had signed receipt and been awcu:e of Policy Directive 854.075, Emplovee'n Relat;oocx
WHb tb;-a DOC Offenders

The emploree was contacted and ded ined intoad,"!J
Signature &Till
of Supervisor:

ADMINISTRATIVE COMMENTS: DA1l! RECEIVED BY OFFICE HEAD

We met on March 21, 1997, to discuss this

EC~.

Personnel Officer and Rick Root, your representative.

After considering the information

available to me, I find that misconduct occurred. Appropriate corrective/disciplinary action
will follow under separate cover.

Signature 01
Olllce Head:

~_. 1006

~

0':"
......~

Ul\lO .1t4·

'JB1tl?

ATrACHME'NT

:1

I

no

I u~

;
OEPARTMENT OF CORRECTlON~

•

'EE CONDUCT REPORT

R E eEl V E [

THIS FORM TO BE USED IN COMPLIANCE WITH POI.ICY DIRECTIve NO. 857.005

FEB 041997
.
INSTRUCTIONS AND TIME LIMITS:
. WASH. CORR. CNTn
1. The person making the report shall provide a clear description of the incident under "Description of Incid/rN9S0NNEL OFFICE'
and, wilh any witness(es) or person(s) having knowledge, shall sign In the space provided and submit to the
Ihe involved employee within fourteen (14) calendar days after the date of discovery of an
supervisor
employee's alleged misconducl.

0'

2. The form shall be submilted 10 the employee involved who shall complete the "Employee's Slatement" and
return the reporl to his/her supervisor within seven (7) calendar days following the dale 01 receipt.
3. The appropriate suporvisor shall review the facts of the incident, complele the "Supervisor's Report" and
submitlhe report to the Office Head within seven (7) calendar days following the date 01 receipl.
4. The Ollice Head or designated representative shall review and within Ihirty (30) calendar days following the
date of receipt determine whether misconduct has occurred. This shall be reported under "Administrative
Comments" and shared with the employee. When the supervisor and Office Head are Ihe same person, the
supervisor's supervisor shall complete the Administrative Comments.
UUOI.OYU IN'IOLvia

George Allen
f'Q$I'1QH

.

CA~'lQH.\I.

u..,

WCC I Infirmarv

UI\I

0.0'II Of' 1HClO.,.,

. Regi stered Nurse 2

1/26/97

I,.. .

c# IHQCIH'

DAM DpM

,

• DESCRIPTION OF INCIDe~IT:

It is alleged that on January 26. 1997. that you erroneously gave a medication to
inmatelllllllll. DOC

4liliiii resulting in

potential danger to the oatient and his

emergency transport to Mason General Hosp1tal.
It'is further alleged that you attempted :0 contact lnmate

~ DOC 411111111L~t

St. Peter Hosoital, also on January 26. 1;97. \·';thout the knowledae of Your

Frank Barth

suoervisor~ ..

/1/1
/1
/ /;<.J /

INITIATED BY:
HAUl! lPUASi """'"

_

I

~1'03"_ "I\l!

ealth Care

~tan::;r

(1\
\

WlTNESSIES!:

b!_
7"

H.....

PO~'_nrLE

jJ.o'\lAI

........

P03"lOH flfLE

!

!

I I

~I

--

2/4/97

-........J

I

I

SlQHA'\lAE

DA'I

DA'I>

DA'E

1007

I_ _...

ATIACHMENT_ _
PAGE

3

..._ ,,-_O.F

/7JL-

I

.,

.

•
DATE DELIVERED TO EMPLOYEE
eNpt.O'(U'S STAreNEHT:

Sillnalufe 01
Employee:
SUPERVISOR'S REPORT:

DATE AECEIVED BY SUPeRV1S0A

Dale:
BY:

Signa lure 0\ Tille
01 SupeNis:lr:

IDMIHISTRATlVECOMMEHTS: DATE RECEIVeD BY OFFICE HEAt'

Signalure ~
Olllee Hea::

Dale:
BY:

Dale:

1008 .
ATI.:..cH MENT

L(

I

OF.l....
U~_"_

•
STATE OF WASHINGTON

DEPARTMENT OF CORRECTIONS
WASHINGTON CORRECnONS CENTER
P.O. Box 900 • Shelton, Washington 98584 .

February 10,1997

TO:

Jerry Tauscher
Correctional Program M
•

, •••#

FROM:

,-

-,

SUBJECT:

:: .~ ..

..
-:.' .......

·

',

·

ECR • GEORGE ALLEN

~

;;'

,

.~:

'';'

.... '." ..- .

~ '",.

......:

..

~

-,

..

·

",: ..

::.~

.

. The Superintendent has designated you as the "Supervisor' or investigator'foith~ ECR
initiated on 02104/97 co,nceming George Allen. The- employee hs·s yet to tum in the
"Employee's Slatemenr which is due on February 11,1997. When this tumed·!n·,·
you will have seven (7) calendar days to complete your investigation.
':.~:~ . ~
-; . ~-: .

is

"

If you have any questions, you may contact me at 5267.

.~::.:::
: :: .. :- "

J

•• ' " , i

-;"

~rpC

cc.

Shalice Ando, Personnel Manager

.....

.
• .::0.
'

:'

-;.

.

10('9

AlTACHME~ I
PAG~ 5 -O-F-:...L-t.,-·)-t:U

•

.ALLEN, GEORGE

.
Employee Name (please Print)

ACKNOWLEDGEMENT OF RECEIPT OF
DOC EMPLOYEE HANDBOOK

,

'. ~.'

....

.:'"_.

I acknowledge receipt of the June 1993 W~hington State Department
.of Corrections Employee Handbook and agree to become familiar
with and have a thorough knowledge and understanding of the<¥.
contents.
'-::
:
"."':,:

--:--..

:.~ar····-:

lOt! hZ',:
Employee ignature

Date

..
~

-,. .--;

. _.....

Original - Personnel File

.

:

-.

. ~~i-.::

1010
A1TACHMENT_ _
i_
PAGE

L,

OF

I 0 i:-

..

, f

•

POLa~Y

DIRECTI'VE
Department of Corrections

No.

PERSONNEL SERVICES

854.075

July 1, 1983

-Effective Date:

Page 1 of
Subject:

2

-EMPLOYEE RELATIONSHIPS WITH DEPARIHENT OF
CORRECTIONS OFFENDERS

-Objective:
~
To provide guidelines to ensure that employee relationships with offenders
are maintained in a professional manner.
Policy:
Relationships with offenders must be conducted in a manner consistent with
state law and prudent correctional practice~ Employees are expected to manage
their relations with offen4ers in a professional manner at all times and· to
treat offenders with respect and dignity.

1. Favoritism: Staff must recognize the individuality of offenders without
, favoritism.- Such.conduct is inherently unfair to both the favored and the
nonfavored. Conversely, grudge holding, bias, or unwarranted negativism
toward or regardi~ an offender is to be avoided. Professional reaction
to offenders must always be- objective and not-based on personal or subjective issues_
2.

Association with Offenders: Association with DOC offenders is to be
avoided in the interest of professional unbiased service. Unofficial
contacts with knomn offenders under the jurisdiction of DOC are to 'be
reported by emplo,ees to their supervisors o~ form DOC 3-39(X). This
does not include casual, unintentional and unsubstancive contacts.
Personal communications and/or relationships between employees and
offenders are not appropriate and are prohibited.

3.

Trafficking: Without specific written approval of the appointing
authority, no employee may give or accept gifts,. gratuities or favors,
have any barter or financial dealings with an offender, an offender's
family or agent. "Gratuit ies" include any fotID of property or services.

4.

!'lessages and Art: ides of Property: Employees !lay engage in the transmi!=··
sion of messages, mail, or articles of property only as part of theirl012
authorized duties_

i- -

ATI'ACHMENT_ _
PAGE_]

--!..D.4-

OF

.
•
.....

•

POLICY '\
DI:R'ECTIVE
I

a:'

Department of Corrections

'~':.
,

"

Page _ _...l7

of

I

2_

s.

Writs and Petitions: Without specific approval from the appointing <Juthority,
employees nre not to,Il8oint, ad.... iae I or counsel offcnder9 1n 'the' prepar.
ation of writs, appeals, or petitions for executive clemency or other legnl ..
concerns of simil"ar nature. Employeea may refeT offendero to the nppropriate legal service agencY.dr person:] for aesistance 1n thORe matterir."

6.

Offander Sponsorship: Employees are not to serVe as furlough sponsors for'
inmates or work/training residents~

.

,

\."

'.

Excc})ttons to this policy rcqui rc t'he written permlltsion from the St:crct<Jry
or his designee.
'.
Supersession:
~olicy Directive 651.005. Eml;loj'ee Relationships with Department of CorrccUons
Offenders. Hay 1', 1982.

".

r.

.:

I · :'.

~.'

~

...

.'... .

~" ....,~ '"'
··i .. : ..... :

.........

.. ,

I .'

t.

'. '.! .;

:

.

'

I have read, discussed, and understand the contents of this Policy Oir'ective.

1'r'ainet'

~.~.~~~..
:

..

ATTA~_·:·f.;.'~~_~_ _.-,

PAGE~OF.~~---"1

\

•

.

OEPARTMENT OF CORRECTIONS ~

REPORT O~ CONTACT WITH A D.O.C. OFFENDER

!

:l.Ul&

CMSIOH OR OffICii

IllSnruflOH OR RaGlaN

Jl)8 1Il\.E (WITH

o.o.c.,

PURSUANT TO l1fE REQUIREMENTS OF DOC POUCY DIRECllVE 854.075, REGARDING EMPLOYEE RELAnONSHIPS WITH D.O.C. OFFENDERS,
THIS IS TO REPORT THAT I HADlHE FOLLOWING CONTACT:
. ""
:
\,CCAnOH OF CONfACf

NAIo\& OF OT)l&R OFFl!NO&R OR ICEH1tI'YIHQ FeAlURE

LENGTH OF CQtlfACT

.

C£SCS\1P1lOH Of CONTACT

.

ClATE Of COHTACT
OATE Of REPORT

.

EMPLOY&£'S SlOAA1\JRE

..
SUl'EJ\VISQR

··'REPORT REVIEWED BY:
nILe

100li

l

:

'- ...... ::.::.~~.:1:.:;. : ~

CONtACT WAS: .

o

o

SlQHFICAHT

KCNSIQHlRC..u.,:,

SUPERINTENDENTIREGIONAL ADMINISTRATOR/COMMUNITY RESIDENTIAL AREA ADMINISTRATOR OR DIVISION DIRECTOR OR oFFIce CH1=~
IF IN HEAOOUARTERS:
SIGNA1\11\&

nTI.E

100TE

I

..

....

"!e'

I

.

.. ..
~

ATTACHMENT

"ACE

1'0

10r~
OFJ

_

DL

•

CHASE RIVELANO
SECRETARY

STATE OF WASHINGTON

DEPARTMENT OF CORRECTIONS

MEMORANDUM
TO:

Phil Stanley
SUPERlNIENDENT

FROM:

wee

date

DATE: Jan 24, 1997

DO'IY OFFICER

SUBJECT: WEEK-END DUIY OFFICER REPORT

place

time

incident

1-24-97

1608

Major Control RICH.I\RDSON 215029 back from St Peter's hospital stay to C€

...

1305
2010

R-2
R-l

.
..

2Q20

R-3

2030
2050

R-3
R-3

"
1-2'5-97

=======
1-25-97

=======

1-25-97
"

"

G6.

HOUI 759363 froIil R2 to l~CC Infirmary/COU
l<ELLEY 633330 (lG5U) and JONES 963530 (lG5L} to Il-nJ/P:'IC
for n"htinp.:
,
.
DAVIS 756290 (3A4) to l-ICC Infirmary - fell in shm'ler, sust
injury to leg.
~

NAJOR COlITROL
0545
=======- ==============
NAJ. CONT.
1325
_======M- ==============
1515
R-.2
R-3
1900

R-3

1945

~

MARCELL 703494 (3'810) to nm/ Ad Seg for secured housing.
BURTON 702476 (3A7) to to nm for possible assault on H.bJH
703494.
NO UrRIES ..

=========================================================
NO Ei'llRIES.
=======================================~================

p~~~ 760235 (2ElO) to l}ID/Ad Se~ for secured housing.
COOK 760390 (3G4) and RETINGER 2:3i;70 (3G4) to nru I PHC
infraction 602. coax also infracted with 660 and 663
~! 759699 (3B5) to JlflJ/Ad Seg for secured housing.

--;.

\

======

1-26-97
1-26-97
1-26-97

-/.

,~~.:.1,.. . C../"( I~ r. .
.....

========= ============== =========================================================
Inmate c1earcoats 0719544 to I.~.U. :or infraction ffl03,~
R-5
1925
Inmate _ _o 1·1ason General Hospital v5.a.
HOSPITAL
2i21
2I:1bulan~ed.Icetion error.
..;;;:
2200
t~CC
!ADMI'ITED NGH f/147

lOf5
ATIACHMENT_---:/_'_ _
O"l·' I\) '3r~.t

~.

Ia

• .:..~~.I'

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PACE---l.L-OF

r.

Or-:I';\ln""w,rr

01: connECT IONS
t>I\TJ-~: 0] n.I./,,.,.
J flC II)J~N'I' U&I'{)ll'I'
"I' 1I,n-:: :::~:.: II ..\"
NO:3817 TYPE:f-1EDlCAL TRANSPORT
STAl--F REPOn'f1NG:LT. IL BJW\'IU
TYPE:
TYPE: .
OCCURRED ON: 01/26/97 AT 08:55PM
REPORTED ON: 01/26/97 AT lO:2SPM

G';";':~': J

HM;U Jtr(;TO'~

LOCATION: WA COR CTR HOSP
PLACE: LIVING UNIT 1
STAFF INVOLVED
INJ HOS

ALLEN, GEORGE

TUFTS-RICH, BETH

WILLIAMS, HAL
MOUNTS, CHERYL
BORCHERS_ BEVERLY
DESCRl~
INMATE
1\S

N
N

N
N

N

N

N
N

N

CONFIDENTIAL: NO
INFIRMARY RM HC02

wee

"FENDE.

N

AD~IINISTEREO

A DOSE OF MORPUI

BY MI£:TAKE AT

. . . . . .~EVELOP~O AN
IOSPITAL BY AMUULANCE

DAMAGE: NO
APPROXIMATE COST: $
O·
fHER AGENCIES CONTACTED: DATE: 01/26/97
TIME: 09:55PM
MASON MEDIC ONE AMBULANCE MASON GENERAL HOSPITAL
HOSP NAME: MASON GENERAL HOSPIT FOLLOWUP RPT: NO AGAINST: INMATE
FFENDERS INVOLVED
o ------------------------. CLOSE
NAMES·4• • •Ift~
LAST KNOWN AOOR:
DOB: 09/30/1969
:
HSC: OTHER VIOL CHILD SEX
RBCEIVED wee-R: 11/15/96
TRANSFER TO PRESENT FACiLITY: 01/22/97
VIC/WIT ELIGIBLB: YES
FURL~
FBI NO: 9S933BJAS
BSA NO~
SID NO: 14237bq4
~OPERTY

•

..

'

-

~

I~
~

:50PM BY GEORGE ALLEN, RN. INMATE
AD\'ERSE RKACTION AND MAS TAANSPOltTED TO MASON GEN
AT 09:05PM.
APPROX

INJ HOS
Y Y

~
~

:....J

tIJ

~ ~

•
STATE OF WASHINGTON

DEPARTMENT OF CORRECTIONS'
WASHINGTON CORRECTIONS CENTER
P.O. SOK 900

•

She/ton. Washington 98584

Ol-~b "'<99-

<:....72J:' Lr.

~207L)/ ",S!.J/Fr· 4t.//~p-;pJ1

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.

'.

•
STATE OF WASHINGTON

DEPARTMENT OF CORRECTIONS
WASHINGTON CORRECTIONS CENTER
P.O. Box 900

•

Shelton, Washington 98584

, :rc:d.\ Cok ~"\Ii."'+ra."tL ·'P:.cLT-{L'-..

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1018
J ._ _
AITACHMENT

~AGE

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OF

11) Ie.

..

I.

•

•

•
STATE OF WASHINGTON

DEPARTMENT OF CORRECTIONS'
WASHINGTON CORRECTIONS CENTeR
P.O. Box 900

•

Shelton. Washington 98584

-,;- 'I.~
~.A1.

I)"

#:J'h ((,;1
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RE.

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ATrACHMENT'
PACE

IS

OF

.

:

r-----~•..-:-.
.1

•

~r:':*II •

~ \1.

---.

STATE OF WASHINGTON

CHASE RIVEtAND
SECRETARY

DEPARTMENT OF CORRECTIONS

:

MEMORANDUM

1

OAT£;:

....<:.

. . _.-._-

/-.:/

SUBJECT:

I

': ..': :.':j:-'

ATTA~~___
'~~~~-'--r~
G

. OFJ c

7-q 7

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all

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FlOrn TfJ£ LLJRE:Y.
TilE .5Am~ /im~ A ,:'/co/C
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To:
NORRIS LAWRENCE
DOC-DP-Cl-LNO
From: ARM~TRONG CLYDE
'DOC-DP-Cl-CAl
Date: Sunday 26-Jan-97 ~_ ~1:07pm
Subj ect: GEORGE ALLE1'f RN
Mr George visted I n m a t e _ at St Peters Hospital at 2009 to 2011.
His visit was without not1fication to Hospital security. They were
concerned and requested that they be notified of anyone coming to the
hospital" for the purpose of visiting/checking on an inmate in the
future.
cc:

BARTH FRANK

DOC-DP-C1-FBC

......... Message amended by: DOC-DP-cf-FBC BARTH FRANK
on: Tue 28-Jan-97 at: 3:20pm
phil, is this the visit you referred to? frank .
....•.... Routed on: Tue 28-Jan-97 at:
From: DOC-DP-C1-FBC BARTH FRANK
To: DOC-DP-Cl-PS4 STANLEY PHIL
*** End of message ***

3:20pm

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STATE OF WASHINGTON

DEPARTMENT OF CORRECTIONS
WASHINGTON CORRECTIONS CENTER
P.O. Box 900

• Shelton. Washington 98584

January 27,1997

G. L. Navarr.o, M.D.

TO:

~/

~.Frank Barth, Health Care Mag;

FROM:

SUBJECT:

:

3~

. Jodi Colema.n, RN
Inpatient Nursing Supervisor
Incident Involving Medication Error.by George Allen, RN 2
My Investigation and Findings

At approximately 9:00 p.m. on January 26, 19997, I received a phone call from Beth
Tufts-Rich, RN 2, stating that she had sent a patient.to the hospital due to a medication
error by George Allen, RN 2. She stated custody was quite upset about a megication
error and wanted to know Dwhy'. She said that the PA had said to send him to Mason
General Hospital. She also stated that the standard procedures and precautions had ,
been observed.
I called her back at 11 :00 p.m. and asked her to call Frank Barth, HCM. She stated she
had already done so.
At approximately 6:55 a.m~27, 19?~d Mason General HospitallCU to
inquire the condition of M ~ DOC ~ The ICU .nurse reassured me
several times the patient was fine. She stated the ER physician had put him ICU as a
precaution only. "He is a very cautious doctor." She stated he was having chest pain
this morning but only after the Corrections Officer asked if he could come back to wce
today.
On January 27,1997, at 7:00 a.m., under my office door I found three.pages of memo
from the 3 - 11 p.m. shift regar~:ng the incident.
.
1) Memo from Tufts-Rich tv LL Brown per order of Elaine Thomas, Duty Officer.
2) Memo from Cheryl MOl:nts, LPN, to J. Coleman, Frank Barth and Gary
McCracken.
3) Memo from Beverly Bor:hers, RN, to Lt. Brown. See attached.

1025

i--

ATrACHMENT_ _

PAGE-d::.LOF

IcL

,"

Or. Navarro I Frank Barth
January 27. 1997
Page Two

On January 27,1997, at 7:00 a.m.• I asked George Allen where his AccidenVlncident
Report was and he provided me with a copy. It only states the error and treatment.
please note the times between ingestion and treatment was 5 minutes. See attached..
On January 27.1997. at 8:15 a.m.• Crystal Nielsen. HCM Secretary, informed me.Frank
Barth. HCM, requested me to do an investigation.
Conclusion a(ld recommendations about why so many errors by George Allen, RN.
My investigation (procedurally)
1.' Checking on the patient's condition at the hcspital, at 9:30 a.m.• I called leu and
patient is being discharged to WCC this a.m. (January 27, 1997). I requested all
the hospital ICU and ER records be copied and sent back with the patient to
establish patient status (my first concern is the patient).
2.

I called the ambulance company, Medic 3. and asked for a copy of the ambulance
report. They said they wil1 fax this information (to avail myself of all information).

3.

I talked with U-E staff involved (essentially an interview), George Allen, RN 2, Allen.,
Riddle, CHCS 2 . and Cheryl Mounts, LPN.
a.

George Allen, RN. gave me a detailed outline of the incident (see attached).
He stated he had ~ven Cheryl Mounts the narcotics keys, then took
them back to giv~his prn med. He then counted the narcotics and
realized he had an error. He reported this error without five minutes and
.orders were received. patient was checked by PA.
..

b.

Allen Riddle, PA-C. stated he had been informed and had acted on the .: "
information. -He provided a written statement to Dr. Navarro who ga'/e me a
copy. Th~re is no notation in the patient's record that reflects this January
27 written statement by A. Riddle. Some appear to be verbal orders and
'should have been in the provider's notes.

c.

Cheryl Moun~s, LPN, was interviewed by telephone and will bring iii a .
detailed written report today. She said that she already received th; narcotic
keys from George and had completed the instrumenVneedle counts with
Doylene Grimes in the treatment room and sterile room at 2:35 p.m. When
she returned to the nurses station, George had asked for the keys tack tt;> 026
giv~ prn med because he was in pain and most uncomfcnablef:
George gave the meds and then started the narcotic count.
.ATTACHMENT
PACE

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•

Or. Navarro I Frank Barth
January 27. 1997
Page Three

4.

Review of medical record (documentation review).
a.

WCC Health Record concludes a medication error was made on January 26
and a provider was notified immediately and orders received.

b.

Mason General Hospital - See aUached. .

c.

M9son county ambulance - Medic I - Not received yet.

Physical examination of the narcotics and the way they are stored.

5.

The two meds (percocet and MS) are stored next to each other and have the
same color wrapper. A work order was sent in on January 24 to have a special
box made with dividers so the narcotic pills are easier to use and to count. (This
is the area where the error occurred.)
6.

Review of procedure for narcotic medications on the inpatient ward (see
attached). They still apply and are relevant.

Conclusion: A serious accident did occur. We are fortunately we had a positive .
outcome.
Recommendations:
1.

Give George Allen, RN, a letter of counseling and review all recent med errors
with him to include a review every month for six months.

2.

A belter AccidenUlncidenl report form. This form must be more specific to . :'':'';'
medication errors. (Could be like the WCC Injury Form and Med. See January
16, 1997, memo from myself).

3.

Review AlIs:l Riddle's notes to Dr. Navarro. If this information is not in :~e chart, it
should have been, especially the vital signs.

4.

Obtain narcotics box for ward narcotics that has dividers.

5.

Delermine why a patienl was senllo Mason General Hospital ER. Vita: signs and
ranges were in Mr. Riddle's notes. (See MGH papers).

..102'7

JC:cn

ATTACHMENT_~l_ _
PAGE

aJ

OF J

GL

•
OEPARTMENT OF CORRECTIONS

ACCIOENTJlNCIDENT REPORT
NOTE: REPORT ALL ACCIDENTS OR INCIDENTS EVEN IF NO APPARENT INJURY.
DATa OF /loCCICEHT OR lflCI1JEHf
I.IOHTH
DAY

lWE
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OESCRIBE LOCATION AND EXTENT OF INJURIES:

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RESULTS OF X·RAY/OTHEROIAGHOSTICTCSTS:

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OISPOSITION:

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HOSPITALIZED

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STATE OF WASHINGTON

DEPARTMENT OF CORRECTIONS
WASHINGTON CORRECTIONS CENTER
P.O. Box goo • Shelton, Washklgtcn 98584

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COLOR
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IV SITE
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TOTAL INTAKE
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ACUTE CARE TRANSFER
NURSING CARE .'
MASON GENERAL HOSPITAL
2100 Sherwood Lane • P.O. Box 1668 •
WhM II) T.-Ieo' Localion

v..,..." Oft Owl

t/:r7/j7

1049

Shelton. WA 985~
PWl OGPJ lor ~
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STAY NUM8~._1146843 SHO •• JTAY

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CITY-STAn
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LIVING Vl\.l :U
PHONE
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DATE Of BIRTH :30-AUG-1969 SEX:n
AGf:021
KOTl fY IN CASE Of EM£RGENCY
ACCIDENT OA1£
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GUARAHTOR NAME :VASHINGTOM CORRECTION CTa
Il£LATION:YAllO/COURT
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GUARANTOR ADOit :PO BOX 900
CITY/STATE: SHELTON '
GUAR CIty-STATE :SHELTON
VA
98584
~~ERGENCY PHONE:(360l425-4433
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ADMISSION - SUMMARY SHEET·

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Type

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AOVAHCE.D DIRECilVE OR UVlNO WILL:
No 0 Yu
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Do you with addltklfW In'ormaUon? (SS)

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0 ArUufb

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IN PLACE ON ARRIVAL

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IL PREVIOUS HISTORY
NEURO
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901 Mt. V~ ..·Or•• P.O. Bot 1668 • Sh.lton. WA 98$.:.£

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Ac:ml SlIMI
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X,Ray RPT's
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F~D~IoIOH024

MASON GENERAL HOSPITAL_
901 Ml Vin'Or,

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P.O. Box 1688 t Sholton,

WA~,

EMERGENCY DEPARTMENT
FLOW SHEET

054

.
.SON
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OUTPATIFNT EMERO-'tCY RECORD

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4~Ar4Y(

1055
:

(iM Cill5

,

•

..

-===========================
DATE

1-26-97

HISTORY OF PRESENT ILLNESS: This is a 27-year-old male per chart
review received a dose of 120 mg MS Contin yesterday evening. He
subsequently became lethargic and improved with Narcan but then
became lethargic again after this wore off. He was transferred to
Mason General Hospital and subsequently disposition was made to
admit him overnight for observation. The patient had been running
a low grade temperature at WCC. He has been having pain in the
heel postop which he states is gradually improving.
Since
admission he has had a temperature maximum of 100.8°; temperature
is 99.5° this morning. He hal no other complaints other than pain
at the operative site.
PAST MEDICAL HISTORY:
Past history is unremarkable.
surgeries include arthroscopy.
ALLERGIES:

Prior

Penicillin,? type of reaction to this.

MEDICATIONS:

Percocet.

PHYSICAL EXAMINATION:
GENERAL:

Pat i entis a we11-develc?ed male in no apparent dis tres~ .

.... _..:.

VITAL SIGNS:
temperature.
HEAD-NECK:

Vital signs are nC=illal with exception of low gr~~e
Heart rate is in -::'e 90s. 02 saturation 96%. . ,"ENT is normal.

LUNGS:

Lungs are normal.

HEART:

Heart is normal.

ABDOMEN:

Abdomen is normal .

.

EXTREMITIES: He has a" cast place:: 0:1. his left lower extremity .:,~~He
has normal sensation in his toes and normal warmth in his toes.
There is no tenderness above t:'e cast or swelling.
No cords
palpable. Negative calf tenderr~~55 on the opposite side.
LABORATORY:

\-lhite count is r.o=::'.:.:.

Urinalysis is negative.

-...

ATTACHMENT
PAGE

.. ~-

'

23 70

~3

DR. ROTH

5J-..

_
OF

I Dy

I

I HISTORY AND PHYSICAL EXAMINATION

i

I

I

MASON GENERAL HOSPITAL
901 Mt. View Drive
Shelton, Washington 9~S84

105S

•

Page 2
ASSESSMENT:

-Status post morphine overdose, resolved.
-Low grade postoperative temperature. Differential diagnosis
would include atelectasis or normal postoperative temperature
from surgery. No evidence of cellulitis at this time.
PLAN: Continue to follow temperature. Repeat white count will be
done prior to discharge. We will continue to have his temperature
monitored at Washington Corrections Center. The fact that his pain
is improving would go against wound infection. Case discussed with·
Dr. Barnard who concurred with this plan.

Jeffrey A. Roth, M.D.
JAR:pah

o

~-27-97

T

1-27-97

0846/0851
0907

cc: Dr. Fred Navarro, Washington Corrections Center

.

ATI'ACHMENT
PAGE

,

_

5" 3 oF1Q ~

HISTORY AND PHYSICAL EXAMINATION
MASON GENERAL HOSPITAL
901 Mt. View Drive
Shelton, Washington 98~84

•

1057

·'-,

•

ADMISSION

Ol-26~97

HISTORY OF PRESENT ILLNESS: This is a 27-year-old male inmate at
wee who received 120 mg of MS Contin p.o. mistakenly instead of
Percocet at about 1500 hours today.
He received Ipecac which
resulted in vomiting followed by activated charcoal p.o. Hewas
noted to be becoming somnolent with decreased respiratory rate at
1930 hours and received Narcan .8 mg IV with improvement in his
symptoms. His symptoms noted to be returning somewhat and he was
transferred to Mason General Hospital for furt~er evaluation at the
recommendation of the P. A. at WCC. He also was noted to have a low
grade temp yesterday and states he is feeling slightly feverish;
however, he .denies other symptoms such as nausea, vomiting, chi:lls,
nasal congestion, sore throat, cough, abdominal pain, diarrhea or
urinary tract symptoms.
He states that his surgical site is
somewhat uncomfortable but not appreciably worse than it has been
since his surgery.
,
MEDICATIONS: Current medications -- Percocet.
ALLERGIES:

.-

Allergic to Penicillin.
"

PAST MEDICAL HISTORY:

No

h~story

of diabetes.

-..

.

PHYSICAL EXA}!INATION: Alert and oriented in no apparent distress.
VITAL SIGNS: Blood pressure 149/52, pulse rate 88, respiratory
rate 22 and te~p 101.2°.
HEENT:'
Norr.:oceohalic, atraumatic.
TMs are nonerythematous
bilaterally.
-partially
obscured
by
cerumen.
Canals
nonerythemato;.:s.
Pharynx noneryt:hematous.
Some black staining
from his tongue is noted from the charcoal.
NECK:

Supple and

CHEST:

nonte~der.

Full range of motion

withou~

pain.

Lungs clear, breath sounds equal bilaterally.
, ......

ABDOMEN:
rebound,

Bo;,'al tones normoactiva, soft and nontender without
guarcin~, distention or organomegaly.

EXTREMITIES: Short le= cast on the left leg.
No lymp~angitic
streaking or sl,o/elling. Toes are "looile without pain. ':oes are
warm. Capillary refill less than 2 seconds.
Fine touc~ in~act
grossly.
DIAGNOSTIC WORKUP: CBe -- white count 9.2, hemoglobin 15.1.
polys and no banas .

.. ~
DR. MALTZ

8~%

EMERGENCY SERVICES REPORT
MASON GENERAL HOSPITAL
901 Mt. View Drh-e
Shelton, Washington 9&S~ •

1058'

•

Page 2

..

ASSESSMENT:
-Narcotic overdose of long-acting oral preparation of
Morphine.
He experienced some mild symptoms by history of
somnolence and with decreased respiratory rate that improved
promptly with Narcan. The patient was discussed with Beth, RN at
wee, and she advised that they are quite full and she does not
believe that they can provide him with close enough observation at
the Infirmary.
-Fever without identifiable source at this time. The patient
is postop Achilles tendon repair on Friday, three days ago. He was
discussed with Dr. Barnard as Dr. Brinkman is unavailable at this
time.
Dr. Barnard felt it very unlikely that the fever' was
secondary to the surgical wound and r~commended that the cast not
be removed. There is no lymphangitic streaking or other clinical
evidence of wound infection at this time. The drainage through .the
cast is not increasing. Urinalysis will be obtained. He has no
cough.
'
He was admitted to the Ieu on a short stay basis to the care
of Dr. Schlauderaff, on call for Dr. Roth, with admission orders
written by me. The patient was discussed with Dr. Schlauderaff anc.
care was turned over to him at that time.

PLAN:

'.

FINAL DIAGNOSIS:

.. ••: "·t·

Narcotic overdose and fever.

Ben R. Maltz, M.D.
BRM:slc
D 01-26-97 2347
T 01-27-97 0749

cc:

- ..

Dr. Schlauderaff

--:-

.

_....

ATTACHMENT
. PAGE

15"

OF~

EMERGENCY SERVICES REPORT
MASON GENERAL HOSPITAL
901 ML View Drive
Shelton, Washington 98584 •

1 05 9

,

"

•

.

DATa

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PROGRESS NOTES
MASON GENERAL HOS?rTA;.
901 MI. View OL. 6:.:g. ,

.

p.o. BOl 16.6a
Shellen. Washington sass:.

1060
a,sGH.Q:1

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PATIENT INFO

CL lENT ltiFO

_ _iiiilif-

AGE: 27 DOB: 0S/30/643 SEX:
PHONE:
ACN: 20004617
STAY: 714&843
CLIN STAT:
REO PHYS: ROTH
PT NUM.
COLLECTED
237013-0

NASON GENERAL

~I

-.\
.....

901 MT VIEW DR.

SHELTON, WA 9SS84

RECEIVED

01/27/'7 03:30

01/27/'7 03:41

REPORTED
01/27/~7

PAGE

4 : 05AM

1

-'.

TESTS RED'D: UA!;U
NOTES:
XX

(COMPLETE)

RESULT AANGE

IN

OUT·

URINALYSIS
SOURCE
COLOR

APPEARANCE
GLUCOSE
BILIRUBIN
KETONES
SPECIFIC GRA~!TY
PH
PROTEIN
UROBILINOGEN

REFERENCE UN ITS

VOID
YELLO
CLEAR
NEG
NEG
NEG

NEG
NEG
NEG

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1.003-1.035

..

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NITRITES

BLOOD.
LEUKOCYTES
WBe
RBC
BACTERIA
EPITHELIAL
CASTS

NEG

NEG

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NEG
NEG

NEG
NEG

1

0-2

H~'F

0-2

HPF
HPF

o
NEG
NEG
NEG
NEG
NEG
NO

CRYSTALS
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CULTURED?

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ATTACHMENT
PAGE

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end of

51

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_
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•

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PAtten Kfh .:.l7Q13-0
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ADMISSION IlIl!E:
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1062 .

~

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NASON

"2

•••••

G~NERAL

Cj01 J'IT V I £\01 DR.

SHELTON, WA

~SSa4

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714&843
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01/2&/Cj7 22:10

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01/26/97 10:28PM

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•
STATe OF WASHINGTON

OEPARTMENT OF CORRECTIONS
WASHINGTON CORRECnONS CENTER
P.o. Box 900 • Sh"'on. W.uhington 98584

January 16, 1997

TO:

All Nursing Staff

FROM:

Jodi Coleman, RN 3
Inpatient Nursing Supervisor

SUBJECT:

Accidenllincident Report, DOC 13-42 & Personal Injury Form, DOC 3·133

Please complete the AccidenUlncident Report form if you have:
a.
b.

Medication error
Injury to inmate, Le., falls in hall, falls out of bed, falls off ER table, etc.

and it is also used if:
c.

there is an altercation between inmates.

Please be sure you make five copies (see distribution list on attached). It is not used If
you wish to report an employee personal injury. You would then use DOC 3-133.
Please advise others if you are injured. If you are sent or go to a physician, please
advise the doctor that you were injured at work. You will then complete an L & I form.
JC:cn
Attachment

..:

ATTACHMENT
PAGE

.

---._

\.e {
1065

I ......

.'
CHASE RIV£LANO •

.... . -.

Secret~'Y

,

STATE OF WASHINCTON

DEPARTMENT OF CORRECTIONS
WASHINCTON CORRECTIONS CENTER
P.O. Box 900 • She/ron, Washington 98584

. August 1. 1996

TO:

.~

~

Nursing Staff.

'FROM:

JoAnn Coleman. RN 3
. Gary Siegel. R.Ph.

~~

®

SUBJ~CT:

Controlled Substance Handling Procedures

.

.

:~.

The following guidelines are provided as a remfnder of the appropriate handling:·'of
controlled substances in this facility. These guidelines are applicable to all nursing
staff EXCEPT those functioning as medication administration staff at designated'
medication lines. It is expected that each individual encompassed by the scope .of this
memorandum will comply with these guidelines.
.J~,.;
_
.,i.l:.
<0 . •

o~li·:·

1.

Controlled substances are to be signed out in sirhe dose increments

2.

Once signed out of working stock. controlled substances are to be administered
immediately.
.

3.

Controlled substances designated on an "as needed" basis are not to be ~igned
out based on anticipated need but on a frequency no oftener than specified by
the practitioner's orders and then only if requested by the inmate."" ~
- ": ..~
.::......
The staff member signing out the controlled substance must be the individual
who administers the medications.
.
. -:t~~

.0._
• -. • .1'
.~.

".

•

5.

-Jt;:

:~T'.'

Verify the inmate's identity prior to controlled substance administration.tt.:·,
-- ~:-

. :'::':j

6.

The staff member administering an oral controlled substance is responsible.for
ensuring the medication has not been cb!3eked .palmed or otherwise con#aled.

7.

The staff member administering any controlled substance is responsible for
documentation of administration on the medication administration record and in
the nursing notes, if applicable.
ATTACHMENT_"_1_ _"_
..

PAGE

\?}

OF_(

ote ~

le6S

.-

'.

-

....
•
Nursing Staff
August 1, 1996
Page Two .

..- •. -

8.

The sign-aut entry in the controlled substance log will include (A) date, (B) time
(in 2400 hour format), (C) quantity checked out (in arabic numerals only),
(D) balance (which must be verified after each entry), (E) inmate name (last
name and first initial or first name), (F) inmate DOC number, (G) prescription
number if avai;able, and (H) full legible signature and title.

S.

Any error made on the controlled substance sign out sheet will be justified!
explained on the reverse side of the page by the staff member making the error.
If that staff member is the not in the facility, the explanation is made by the staff
meml1er discovering the error if possible, Le., math error, wrong sheet, etc.
.

10.

Disposal of unused or partially used controlled substance shall be witnessed by .
two medical ~taff members and attested to by the same with their signatures on
the back o(the sign out sheeL A brief explanation of the reason for destruction
must precede their signatures.

11.

If the required dose of an injectable controlled substance is less than that
contained in the syringe, the quantity to be wqsted!destroyed will be expelled in
the presence of a witness utiliZing guideline #10 and the remainder then.
administered te the patient. .

12.

When conducting controlled substance inventory (counts), each staff member
must witness the actual count and the documentation of the count in the
controlled substance log for accuracy prior to signing each document. The staff
member conducting the actual count should not know the quantity of controlled
substance indicated in the controlled substance log.

13.

If partiallablets are found in working stock which are unidentifiable, notify the
pharmacist who will assist with disposal.

14.

If a seal is broken on an injectable controlled substance held in working stosk.
the drug should be held in working stock until destruction/disposal by '. ~.~.
appropriate phannacy staff can be completed.
-:'~~~,,:
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15.

If an error is made when making an entry in the controlled substance log,-:-draw a
single line through that portion of the entry in elTOr and make and initial the
correction. The portion of the entry in error must remain legible.

:cn
.~TI.:,t'HMENT_··

PAGE

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1067

,

•

NURSING PROCEDURE
INPATIENT ORDERS
MEDICATIONS:
1.

Advise the physician/provider that medication orders need to include:
'a
b.
c.
d.

2.

Date
Time - must have exact time
Controlled substance ordered must also include Form DOC 13-15
(This must be identical to the Inpati~nt order to be valid.)
• Exact length of time of the medication being ordered, i.e., 24 hours,
48 hours. 72 hours, 96hours OR 2 days, 3 day. 7 days (each day equals
24 hours)

Telephone orders must include:

1 a.• b., c., d., and Form DOC 13-15, if applicable..
These orders are to be signed as soon as possible.

3.

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All orders are to be legibly signed.

.-

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4.

When transcribing medication orders, the nursing staff will bracket the order with
{ } date, time, a clear complete signature and their name stamp on each copy.

5.

The order must be comcletelv reviewed for completeness and Form 13-15 for
exactness and completion before taking to the Pharmacy.

6.

If orders are unclear, the nurse attempting to transcribe is responsible for .~.
returning the order to the physician/provider for clarity. then delivery them to the
Phannacy.
.
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ATTACHMENT~··

PAGE

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1063

•

NURSING PROCEDURES'
MEDICATION RECORD -INPATIENT:

1.

A medication record DOe 13-16 is to be prepared by the nurse who transcribes
the first medication order.

2.

This medication record will contain complete information:
a.
b.
c.
d.
e.

f.
g.

3.

Inmate: Name (Last. first, middle) printed
Facility: wee Inpatient (Ward)
DOC # clearly printed
•Month and year
All allergies are to be printed in red
The name of the nurse who transcribed these orders and prepared-this
medication record will be printed irt..the lower right corner.
"Name Alert" shall be printed in red directly below the inmate name if the
chart has indicated name alert.

Medication: [Rx]

a.

b.
c.

d.
f.

g.

h.

Nam'3 of the medication - both the ordered name and the generic drug
supph~d by the pharmacy.
Frequency - i.e., QID. TID, PRN. q 4 hours.
Amount, Le., 1 tab, 1 cc.
Route of administration, i.e., oral (p.o.), 1M, IV, rectal, etc.
Physk..ian/provider.
Start date and time, if applicable.
End date and time, if applicable.

•

4.

At the top of DOC 13-16, must have the provider (nurse) name - clearly written
and initialed.

5.

If the medication is ordered on any other date than the first day of the month,
use a wide-top fe It marker to draw a line to the correct start date.

6.

If the medication order spans into the next month and space is available on the
medication record, the Rx may be written and labeled with the month (Le.,
August) in the left margin. If the record has insufficient space, a new medication
record must be prepared for the following month.

7.

Renewing medication(s) orders, except controlled substances, may be continued
on the same Rx as the Medication Record if there is no change in dose,
frequency or ioute of administration. This is accomplished by running a red I;,e
through the start and end dates and putting in-new dates in red. This also ,
applies to a Physician/provider change.

10B"'S.TTACHMENT
PAGE

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5" OF \ C'~ .

NURSING PROCEDURE
Page Two
MEDICATION RECORD -INPATIENT:
8.

Orders to stop medication or change the order are to be effective immediately.
The medication record will be marked by:
a.
b.
c.

A diagonal line through the Rx box.
A wide felt marker line following the last dose given.
Under the wide line, the nurse who transcribed the order will write DC or
change, write their name, date and stamp.
0

9.

Medication orders that are changing or Discontinuing medications will cause the
nurse to return the medication to the pharmacy along with the orders (yellow
copy of the PER).
,

10.

Controlled substance changes require the provider to write a ~ order and
DOC 13-15 and a new Rx section on the Medication Record to be completed; as
described in (3 above).

11.

Medication given past the ending time of the order constitutes a medication
error, thus requiring the nurse to complete an incident report with copies °to the
nursing supervisor, pharmacy. health care manager and medical records.

12.

Medication(s) that are refused by the patient are to be marked on the medication
record on that dose/time with a red (R). Precharting of medication can
po~entially be a liability.
7-9-9~
Date

ATrACm.mNT_-..,;:...-_

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Department of Corrections
DIVISION OF PRISONS

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TITLE

PHARMACEUTICAL SERVICES - CONTROLLED SUBSTANCES
AUTHORITY: COP 420.540
PURPOSE: To provide procedures for handling and conlrol of all controlled substances.
APPLlCABILllY.: Applies to all WCC staff.
DEFINITIONS:
. Controlled Substance: A drug substance or immediate precursor of such drug or substance so
designated under or pursuant to Chapter 69.50 RCW,Ahe Uniform Conlrolled Substance Act.
Resoonsible Pharmacist: A licensed pharmacist placed in charge of a pharmacy by a
.nonlicensed proprietor/owner.
Every portion of the establishment coming wider the
jurisdiction of the pharmacy laws shall be under the full and complete control of such
responsible phannacist.
.
FIELD INSTRUCTION:
The Pharmacist Supervisor/Responsible Pharmacist is responsible for all controlled
substances.
Controlled substances stocked within the pharmacy are stored in a lacked cabinet. The
cabinet key is on each pharmacist's key ring. In an emergency. designated medical staff may
contact the phannacist or pharmacist superviscr in order to facilitate withdrawal of controlled
substances from Vault/Pharmacy stock. Controlled substances removed from the pharmacy
must be signed cut in the Vault/Pharmacy Controlled Substance Log which is also .stc?r~d in
the cabinet. Wrtndrawals of controlled subst2:ices from the pharmacy must immediately be
entered as a receipt in tt'\e appropriate work station Controlled Substance Log.
~~~:~~
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Each receipt of a controlled substance is imrnsdiately documented in the VaultJPh~rmacy
Controlled Substance Log. Documented information indudes current date; quantity received;
Field Order number; current balance; and full signature and title. Perpetual inventory··of all
controlled items shall be maintained at all times.
. '.
Pharmacy stock of controlled substances is s:ored in two locations within the institution.
These locations are: 1) the locked cabinet within the pharmacy and 2) the controlled
substance vaull :ocated in Major Control: Fe( seOJrity reasons. the bulk of all controlled
substances within the institution is stored in the vaull Vault storage is inaccessible except to
ATTACHMENT

1071

PACE

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Department of Corrections
OlVlSI9N OF PRISONS

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PHARMACEUTICAL SERVICES· CONTROLLED SUBSTANCES
the two institution pharmacists and the Superintendent. The Superintendent maintains a
duplicate vault combination in a sealed envelope, plainly marked. and filed in another safe.
Inventories, inspections, searches or shakedowns are never made in the controlled substance
vault or pharmacy locked cabinet except in the presence of the responsible pharmacist.
Once each quarter. the Superintendent or designee appoints a staff member not assigned to
health services to conduct jointly with the responsible pharmacist and the health authoFity an
inventory of all controlled items. Verification of inventory is documented in the Vaultl
Pharmacy Controlled Substance Log indicating date, Jhe word "inventory", current balance,
and signatures of all members of the inventory team. Discrepancies, if any, are reported to
the Superintendent. Washington State Board of Pharmacy. and Drug Enforcement
Administration as applicable. When personnel changes involve the health authority or
responsible pharmacist. a controlled substance inventory shall be performed and all
appropriate documentation reviewed. Vault combinations· are changed whenever personnel
changes involve the responsible pharmacist or the Superintendent.
Expenditures of controlled substances from the vault stock are documented in the appropriate
section of the Vault Controlled Substance Log. Documentation information includes: 1) date;
2) amount withdrawn; 3) current balance; 4) destination of issue. and 5) full signature and title.
Whenever possible, this procedure is carried out by the responsible pharmacist.
A working stock of controlled substar.ces is held in a double locked storage in the Medication
. Room and in the inpatient workstation (nurses station). Receipt of controlled substances into
either stock is entered in the appropriate Controlled Substance Log indicating date" time,
amount received, current balance, source of receipt, signature, and title. Expenditures of
controlled substances from the Med:::ation Room supply are documented in the Medication
Room Controlled Substance Log inc1cating date. time, amount withdrawn, balance, inmate
name, inmate DOC number, prescription number, signature, and title. Expenditures of
controlled substances from the nurses station supply are documented on the Inpatient
Controlled Substance log indicating time, inmaie name, DOC number, providers name.
dosage, any amount wasted. amour.t withdrawn in the appropriate column and medical 'staff
person's signature and title. If any q:Jantity of the dose withdrawn is wasted, the destruction
must be witnessed and co-signed by a second medical staff person. Documentation is
provided for each expenditure from Controlled Substance stock. Except in the case of
extreme emergency, controlled subs-.ances shall not be drawn from nurses station stock for
'
outpatient use or from medication roo:n stock for inpatient use.
A1TACHMENT

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Number

DIVISiON OF PRISONS

WCC 650.570

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iN·Sr·RUCTION
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Page 30f5

PHARMACEUTICAL SERVICES· CONTROLLED SUBSTANCES
Pharmacy staff monitor controlled substance stock levels in the medication room and
replenish this supply in quantities to meet antidpatedlpossible requirements. Inpatient nursing
staff monitor controlled substance stock levels in the nurses station. New stock or restock
items are requested via a preprinted form which must be signed by two health care providers
and delivered to the pharmacy. Controlled substance items are supplied in minimum
quantities as indicated on the order form and must be ordered/reordered in those quantities or
multiples thereof. Filled orders for bulk controlled substances are delivered to nurses station
'by the.pharmadst and receipted for by two health care providers on the order/reorder form.
Order/reorder forms remain a portion of permanent pharmacy .controlled substance records.
Nursing staff are responsible for entering all controllE!d substance receipts on the controlled
substance log. Such entry includes the time, the statement "from pharmacy" or other source, if
applicable, the quantity received in the appropriate column and the signature of two medical
staff providers completing the entry.
In some instances, controlled substances may be stocked in the nursing station which are not
included on the preprinted inventory listing on the form. In those instances, the drug name
and strength must be entered in a column at the top of the page when initially received··in
stock.

A new inpatient unit controlled substance log sheet is initiated at midnight and is utilized for a
24 hour period. Utilization of a new form includes completion of the following items: 1) page
number, 2) date, 3) balance brought forward from the previous 24 hour period at the top of the
. page and 4) the signature of the transcrjber in the same block as the wording "balance
brought forward'". At the end of the 24 hour period, the ending balance is tabulated 'at the
bottom of the page. The completed log sheet is then photocopied and the original form
delivered to pharmacy trrough the access pan in Room 38. The copy is retained in the
nurses station for a period of 30 days.

Arl inventory of all controlled substances stored in the Medication Room and in the nurses
station is carried out at the change of each shift by a member of the oncoming and offgoing
shifts. Each .controlled substance stocked is physically counted by tablet, capsule, milliliter,
etc., and documented in the Medication Room or Nurses Station Controlled Substance Log.
Ooo..mentation includes date, time, the words "count correct/count incorrect", quantity
inventoried, and signature of each health care·provider involved.
Under unusual circumstances, controlled substances may be transferred between Medication
Roor:1 stock and Nurses Station stock. Such transfers require two staff persons, one
responsible for each stock, to complete {he entry on each log. Entries include date, time,
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DIVISION OF PRISONS

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WCC 650.570

'FIELD
INSTRUCTION
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PHARMACEUTICAL SERVICES· CONTROLLED SUBSTANCES
-transferred to· or -received from- (indicating Medication Room or Nurses Station), the quantity
of controlled substance transferred and the signature of each staff person on eaCh log.
Transfers from one stock are immediately listed as receipts in the receiving inventory. In
addition, when controlled substances are transferred between working stocks, phannacy is
notified immediately by memo indicating drugs transferred, source and destination, ~nd the
reason necessitating the transfer.
In the absence of the pharmacist, discrepancies that cannot be immediately corrected are
reported in writing by the inventory team to the responsible pharmacist. 'If the responsible
pharmacist is unable to reconcile any discrepancies,'a MiHen report is made to the Health
Care Manager, Captain/Shift Lieutenant, and, if applicable, to the Superintendent,
Washington Slale Board of Pharmacy, and Drug Enforcement Administration.
Attached are general controlled substance handling
outpatient nursing staff.

pr~dures

for inpatient nursing and

PROCEDURE:
RESPONSIBLE PERSON

Responsible Phannacist

SEQUENCE

ACTION TAKEN
Stores and conlrols all controlled substances
seOJrely.
Maintains dccumentation of all receipts and
withdrawals of controlled substances from
pharmacy or vault.
Attends all imentories, inspections, searches or
shakedo'M1s of controlled substance -storage
areas.
.."_
Maintains a worr<ing supply of controlled
substances in Medication Room storage
cabinel
Provides working
supply of controlled
substances for nursing station stock. upon

1

2
3

4

5

proVo'r requ;;;;,
6

Conducts imoantory of all controlled substances
on a quarte.-:y basis in conjunction with health
authority ana appointed staff.
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orvIs IbN OF PRISONS

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PHARMACEUTICAL SERVICES - CONTROLLED SUBSTANCES

7

Monitors inventory and uses documentation
provided by clinical staff for' all controlled
substances provided from Medication Room and
Nurses Station stock.
Maintains documentation of all receipts and
withdrawals of controlled substances from
Medication Room and Nurses Station.

S

Nursing Staff/Medical Provider

g

Documents each withdrawal and receipt, if
applicabie, of controlled substance from
Medication Room or Nurses Station stock.
Conducts inventory of all controlled substance
stock stored in the Medication Roam ~ "and
Nurses Statil?n at change of each shift.

10

REVIEW: This field instruction is reviewed annually.
REFERENCE:

MSS 13.47

SUPERSESSION:

WCC 650.570 dated SMar95

ATIACHMENTS:

GARY McCRACKEN, Heillth Care Manager

. DATE

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DATE

PHIL STANLEY, Superintendent

DATE

ANDREA BYNUM, Command Manager
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CONTROll

.
1.

eo, SUBSTANCES HANDLING PRoceOUf -~ FOR
JRSING STATlOH ....EDICALSTAFF

Controlled substances are to be signed out in single dose increments only.

2. Once signed out of working stock. controlled substances are to be administered immediately.
3.

Controlled substances designated on an "as needed" basis are not to be signed out based on anticipated need
but on a frequency no oftener than specified by Ute practitioner's order and then only if requested by the inmate.

4.

The staff member signing out the controlled substance must be the individual who administers the medications.

5.

Verify the inmate's identity prior to controlled substance administration.

6.

The staff member administering an oral controlled substance is responsible for ensuring the medication has not
been cheeked. palmed or otherwise concealed.

7.

The staff member administering any controlled substance is responsible for documentation of administration on
Ute medication administration record and in the nursing notes. if applicable.

8.

The sign-out entry in the controlled substance log will include: 1) date, 2) time (In 2400 hour format), 3) inmate
name (last name and first initial or first name). 4) inmate DOC rr~mber, 5) name of provider, 6) dose. 7) quantity
wasted, if any, 8) quantity checked out (In arabic numerals only), 9) balance, and 10) rullleaible signature(s)
and tiUe{s).
"

9.

Any error made on the controlled substance sign out sheet will be justifiedl explained on the reverse side of the
page by the staff member making the error. If that staff member is not in the facility. the explanation is made by
the staff member discovering the error if possible. Le., math error, wrong sheet, etc.

10. Disposal of unused or partially used controlled substance shall be witnessed by two medical staff members and
attested to by the same with their signatures on the sign out sheet Abrief explanation for the destruction is to
be documented on the back of the sign out sheet
11. 1C the required case of an injectable controlled substance is less than that contained in the syringe, the quantity
to be wasted/d:stroyed will be expelled in the presence of awitness utilizing guideline #10 and the remainder
then administer;1 to the patient

12. When condudi:~ controlled substa"nce inventory ::our.:::,. each staff member mus, witneSS the actual.count
and the docume~tation of the count in the controlS~ SUt:~nce log for accuracy priCi to signing each document
The stc:~ memc-:: conducting the actual count si':ould nc: Know the quantity of controlled substance indicated in
the controlled s::~stance log.
"
13. If partial t2blets are found in \'larking stock which are uni~entifiable, notify the pharmacis~ who will assist with
disposal.
14. If a seal is bro;"::! on an injectable controlled sut~iancs i:~ld in working stock, the drug s~ould be held in
working stock t.:::til destruction/disposal by apprccriate ~i1armacy staff can be completed.
15. 1C an error is m==~ when making an entry in the c:ntrol~ substance log, draw asinole fine throughthat portion
of the entry in e::or and make and initial the corr:-don. Tne portion of the entry in error must remain legible.

1076'Tl'ACHMENT
PAGE J.h

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. .

CONTROllf

3UBSTANCeS HANDLING PROC
OUTPATIENT NURSING STAFF

URESFOR A~~
PAGE

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1.

Controlled substances are to be signed out in single dose increments only.

2.

Once signed out of working stock, controlled substances must be administered at the
next medication line except in th~ cases of -no shows- or -refusals'.

3.

4.
5.

The staff member signing out the controlled substance must be the individual who
. administers the medications.
Verify the inmate's identity prior to controlled substance administration.
.
.
The staff member administering an oral controlled substance is responsible to ensure
to the greatest extent possible that medication has not been cheeked. palmed or
otherwise concealed.

6.

The staff member administering any controlled substance is responsible for
documentation of administration on the medication administration record.

7.

The sign-out entry in the controlled substance log will include: 1) date. 2) time (in
2400 hour format), 3) quantity checked out (in"arabic numerals only), 4) balance
(which must be verified after each entry), 5) inmate name (last name and first initial or
first name), 6) inmate DOC number. 7) prescription number if available and 8) full
legible sign~ture and title.

8.

Any error made on the controlled substance sign out sheet will be justifiedl explained
on the reverse side of the page by the sta;f member making the error. If that staff
member is not in the facility, the explanation is made by the staff member discovering
the error if possible, Le., math error, wrong sheet, etc.

9.

Disposal of unused or partially used controlled substance shall be witnessed by two
medical staff members and attested to by the same with their signatures on the back
of the sign out sheet. A brief explanation of the reason for destruction must preceded
their signatures.

10.

When conducting controlled substa~=c iO'lsntory t:ounts). each staff member must
witness the actual count -and tne ocC'.:me:-.:ation 0; the count in the controlled
substance log for accuracy prior to s:gilin; each cocument. The staff member
conducting the actual count should n:t kr,:lw the quantity of controlled substance
indicated in the controlled substance iog.

11.

If parti~1 tablets are found in wOr't<ing Stoc:·. which are unidentifiable, notify the
pharmacist who will assist with disposal.

12.

a seal is broken on an injectable ccmro~€d subsiance held in working stock, the
drug should be held in working stock :.:nti: destruction/disposal by appropriate
pharmacy staff can be completed.
,
If an error is made when making an entry ~ the controlled substance log, draw a
sinole line through that portion 'if the emil in erro; and make and initial the correction.
1 077
The portion of the entry in error must remain legible.

13.

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NURSES STATION
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DATE: _"
SUPPLY
In hand

.-ROLLED SUBSTANCE

_
QUANTITY
REQUESTEO

R.DER FORM

(PHONE ORDERS WILL NOT BE ACCEPTED)
OESCRIPTION

MINIMUM
QUANTITY

ORAL
Acetaminophen/codeine 30 mg
Clonazepam 1 mg
Diazepam 5 mg
Lorazepam 1 mg
Methadone 10 mg
MS Cantin 15 mg
MS Cantin 30 mg
MS Cantin 60 eng
Oxycodone APAP 5/325
Pentazocine/Naloxone 50/.5
Phenobarbital 30 mg
Other
Other

PHARMACY
at sent & Lot 1#

20
25
20
10
25
25
25
25
25
25
10

INJECTABLE
Diazepam 10 mg/2 ml
Lorazepam 2 mg/ml 1 ml (Refrigerate)'
Meperidine 50 mg Inj.
Meperidine peA
Morphine 10 mg Inj,
Morphine peA
Other
Other

1
5
10
1

10
1

.
.
SIGNATURE OF TWO ORDERING HEALTH CARE PROVIDERS:
. Requesting

Co-Signature

SIGNATURE OF PHARMACIST FlUNG ORDER:

Date Filled

Signature of Pharmacist

SIGNATURE OF TWO RECEMNG HEALTH CARE PROVIDERS:

Signature/Daterrime.

1

Signature/DateITime

,

10

1Y'ACHMEN'T_'_\-PAGE....2i-oF \

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STATE OFwASHrNGTON

DEPARTMENT OF CORRECTIONS
WASHINGTON CORRECTIONS CENTER
P.O. 80x 900

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STATE OF WASHINGTON

DEPARTMENT OF CORRECTIONS
WASHINGTON CORRECTIONS CENTER
P.O. 80Jc 900

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Shelton, washington 98584

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STATE OF WASHINGTON

DEPARTMENT OF CORRECTIONS
WASHINGTON CORRECTIONS CENTER
P.O. Box 900

•

SIlsncn, W':l$l1lrlgron 98584

January 27, 1997
To:

From:

G. L. N"v;mo, MD

Subject: 1uvestigalion report of the incident that occurred on January 26,
'1997.
"

Ellclosures:
I. St"lolI,enl from PA-C Riddle
2. SWtcment from PA-C Williams
3. St"temenl from Mr. George Allen RN
4. Strttetnenl from Nursing staff on duty: Ms. Tufts-Rich, Ms.
Mounts, Ms. B'lrchers
5. Nursing instructions and procedures on handling ofmedic3tt0l1S

At "pproxim"lely 1445. Jm,u",)' 26.1997 MS Cantin 120 mg, (an oral
Illorphinc prepnr;llion) ordered for another inmate was inadvel1ently given by

Mr. George !\lIell RN, by his own <ldmissiol1, to another patient, inmate
_PA-C Riddle lVas immedialely notified and gastric, .
emptying procedures were promptly started. The patient was close!;'
observed for any ulltoward occurrence and eventually transferred al 2120 for
more intensive observation, (0 Mason General on orders ofPA-C Williams
after he received phone rep0l1s that Mr~as becoming more
sedaled with slun'ed speech and dilated pupils, All the steps needed to be sure that the pal ienls health is not placed in jeopardy after the incident, was ,
nccomplished in :1 timely fashion.' Verbal rcp0l1"from MGH this morning was
encouraging, in that they did 110t observe any untoward side effects of this
incident "nd wi;1 tmnsfer the patient back to us sometime today. Mr, Allen
was involved il~ 311 incident of a similar nature approximately two weeks ago,

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and admitted to a total of 4-5 other similar en·ors in his seven years
employment at WCC.
Review of the nursing procedures indicated that there are documented
instructions to ensure that the proper dose and medications are given to the
right patient for controlled substances. I do not see any instmctions of a
similar nature for drugs other than controlled medications. There are also no
instructions that J could find on how to document these incidents and what
steps the nursing service have to do in order to correct any deficiencies in the
quality of patient care, if required. This incident appears to be a simple case
of the nurse not paying attention to the necessary steps needed in order to
carry out fhe physician's or providers medication ord~rs accurately. There is,
however, the need to have a revised medications instruction to clearly state.
the steps needed to ensure that all medications are administered properly and
accurat~ly in a timely fashion. There should be continuing emphasis on the
strict adhercn~c h) these steps during regularly recorded meetings by the
nursing stnfTs. I r a pattern or illcid~nts appear to OCCUl" on the same
individual, a process of action to help rectify the problem should be clearly documented in a separate instruction. Finally I would recommend that the 0.: _
nursing supervisor revisit the previous incidences that Mr. Allen was
involved in, rind recommend a plan to assist this individual who appears to be
experiencing some difliculties at this time.

.

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CHASf: 'RIVELANO

Secrewy

, STATE OF WASHINGTON

DEPARTMENT OF CORRECTIONS

MEMORANDUM

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DATE:

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STATE OF WASHINGTON

DEPARTMENT OF CORRECTIONS .
WASHINGTON CORRECTIONS CENTER
P.O. Bo% seo

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STATE OF WASHINGTON

DEPARTMENT OF CORRECTIONS
WASHINGTON CORRECTIONS CENTER

P.O. Box 900 • SheUon. Washington 98584

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STATE OF WASHINGTON

DEPARTMENT OF CORRECTIONS
WASHINGTON CORRECTIONS CENTER
P.o. Box 900

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Shelton, Washington 98584

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Cw..sE RIVELANO

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Secret~'y

STATE OF WASHINGTON

DEPARTMENT OF CORRECTIONS
WASHINGTON CORRECTIONS CENTER
P.O. BoJC 900 • Shelton, Washinston 98584

. August 1, 1996

~

TO:

Nursing Staff.

FROM:

JoAnn Coleman, RN 3
Gary Siegel, R.Ph.

SUBJECT:

Controlled Substance Handling Procedures

~~

®

,

The following guidelines are provided as a reminder of the appropriate handling of
controlled substances in this facility. These guidelines are applicable to all nursing
staff EXCEPT those functioning as medication administration staff at designated .
medication lines. It is expected that each individual encompassed by the scope of this
memorandum will comply wUh these guidelines.
'
1.

Controlled substances are to be signed out in sirte dose increments only.·

2.

Once signed out of working stock, controlled substances are to be administered
immediately.
"

3.

Controlled substances designated on an "as needed" basis are not to be ;;igne<i
out based on anticipated need but on a frequency no oftener than specified by
the practitioners orders and then only if requested by the inmate.

...
'

.-:"..4''

'.

The staff member signing out the controlled substance must be the individual
who administers the medications.

5.

Veriiy the inmate's identity prior to controlled substance administration.

6.

The staff member administering an oral controlled substance is responsible for
ensuring the medication has not been cl)j3eked .palmed or otherwise concealee.

7.

The staff member administering any controlled substance is responsible for
documentation of administration on the medication administration record and in
the nursing notes, if applicable.
,-

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ATTACHMENT

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•
•

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Nursing Staff
'August1,1996
Page Two

8.

The sign-out entry in the controlled substance log will include (A) date, (B) time
(in 2400 hour format), (C) quantity checked out (in arabic numerals only),
(0) balance (which must be verified after each entry), (E) inmate name (last
name and first initial or first name), (F) inmate DOC number, (G) prescription
number if avatable, and (H) fullleqible signature and title.

9.

Any error made on the controlled substance sign out sheet will be justified/
explained on the reverse side of the page by the staff member making the error.
If that" staff fT,ember is the not in the facility, the explanation is made by the staff
member discovering the error if possible, i.e., math error, wrong sheet, ere.

10.

Disposal of unused or partially used contrplled substance shall be witnessed by .
two medical ~taff members and attested to by the same with their signatures on
the back o(the sign out sheet. A brief explanation of the reason for de~truction
must precede their signatures.

11.

If the required dose of an injectable controlled substance is less than that
contained in the syringe, the quantity to be wasted/destroyed will be expelled in
the presence of a witness utilizing guideline #10 and the remainder then
administered to the patient. .

12.

. When conducting controlled substance inventory (counts), each staff member
must witness the actual count and the documentation of the count in the
controlled substance log for accuracy prior to signing each document. The staff
member conducting the actual count should not know the quantity of controlled
substance indicated in the controlled substance log.

13.

If partial tablets are found in working stock which are unidentifiable, notify tne
pharmacist who will assist with disposal.

14.

If a seal is broken on an injectable controlled substance held in working stock,
the drug should be held in working stock until destruction/disposal by
appropriate pharmacy staff can be completed.

15.

If an error is made when making an entry in the controlled substance log, draw a
sinale line through that portion of the entry in error and make and initial the
correction. The portion of the entry in error must remain legible.

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1090
'\TTACHMENT_ _'_ _
P.\(;F.

gl:, OF".l.Dl.

.. ..
•

STATE OF WASHINGTON

DEPARTMENT OF CORRECTIONS
WASHINGTON CORRECTIONS CENTER
P. O. Sox 900 •

Shelton. Washington 98584

February 8, 1994

TO:

All Nursing Staff

FROM:

Jodi Coleman, RN 3 ~

SUBJECT: 'Pre-packaged Preseriptions
The Items on the attached list are available to the nursing staff as nursing prepackaged prescriptions. These items are located In Drawer #5 of the Documed.
These pre-packaged prescriptions may be used after the nurse secures an order from
the PA or MD If the pharmacy Is clQsed.
To use the Documed In this manner, requirements are:

1. An authorized key.
2. Leave documentation for any item(s) removed. (Leave the documentation any
place in the Documed.)
3. Completion of information on the pre-packaged prescription label:
a. Inmate name (complete)
b. Inmate DOC number
c. Date of Issue
d. Complete directions for use by the Inmate.
e. Name of drug and number issued
f. Expirationdate
g. Name of prescribing practitioner

-.
Insurance: Consider after completing all required information on the pre-packaged
prescription the photocopying of this package to protect yourself.
-'

If a medication/prescription Is needed for an emergency, the nurse must call/contact
the PA not the pharmacist. The PA may call the pharmacist.
.
If any or all of the nursing staff want a demonstration of this memo, please contact
Gary Siegel, R.Ph.
Mached is the WAC 246-869-120, Mechanical Devices.
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Machments

•

STATE OF WASHINGTON

DEPARTMENT OF CORRECTIONS
WASHIHGTONCORREcnONSCENTER
• P. O.80Jt 900 • Shelton. Washington 98584

,February 3, 1994

TO:

All Medical Providers

FROM:

Gary Stegel, R.Ph.

SUBJECT:

Pre-Pa~k Prescriptions

The following medications are available as nursing pre:'packs, effective date
February 7. 1994.
"
..
MEDICATION

Amount In pack

# of pre-packs

Albuterollnhaler

ea

3

AmoxJK Clavulantate 250 mg

10

2

Belladonna 'w/Pb X tabs

10

2

Cephalexln 500 mg caps

13

2

Clonldine 0.2 mg tabs

10

2

Diphenhydramine 50 mg caps

10

2

Erythromycin 250 mg tabs

13

2

Hydroxyzine 50 mg tabs

10

2

.

;:.! .:

20

4

LIndane Shampoo

20z

2

Metaproterenol Inhaler

ea

3

Methocarbamol 750 mg

20

3

Midrin (generic)

12

2

Nitroglycerin 1/150 gr S.l.

25

2

Prochlorperazine 10 mg caps

7
7'7

2

SulfamethlTrimeth
GS:cn

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-....

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Ibuprofen 400 mg

Ranitidine 150 mg

....

2

2

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WAC 2~6-869-I20 Mecbaniol dtTIcn '" .......... -._MechaniClI devices for storage of
-toclc. shall be
limited to hospit3.I.'i"and shall comply -.-. ... alllhc (ollow*
ing provisions:
.
(I) All drugs and medicines to be stocked In the dcvie;: sh311 be prepared for usc in the devic::: by. or .under
the: direct supervision of ::L registcred pharma.clst In the
crr
' of the hospit:l.l and sh311 be prep3rc:d In ~hc: haspit,]. Ifom the hospital stock in which the: drug I~ to b.c
administered. • Hospital" shalt me:ln 3ny hOSpHJI Jt.
c:::nscd by the state dcp:lttment of health o~ u~de~ the
direct supcfYision of the state: dcp3rt~cnt of institutions.
(2) Such device shall be Slocked ~11h. drugs and medicines only by 3. rcgistc~ed ph:l.rmaclsl 10 the employ of

no

the hospit:11.
(J) A registered pharm::lcist in the employ of the hos-,
pilJI sh:1l1 be personJlly responsible (or the. inventory
and stocking o( drugs and medicines in the d~v~e::: and he
shJlI be personally responsi.ble for th.e condition o( the
drugs and medicines stored In the deVice.
(4) A registered ph:HmJ~ist in .the employ of the hospit:!1 shJlI be the only person haVing 3ccesS to th;lt par·
tion, section. or part of the de'/ie::: in which the drugs or
medicines Jre stored.
(5) All containers o( drugs or medicines to be stored
in the device shall be corn::ctly labeled to inc!u.de: Name.
strenglh. route of Jdministr:Hion and i( :lpphoble. the

\ I •

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.. _ ..

ploy of the bospiLaI' - '1:111 not inclUde :1lIy pfu.mueisc
who U. or is ~p'oy~_ by. Ol ItUnu(;1etUrer. wholesaler.
distribucor. or itincr.1nt vendor of drugs or medicines.
(12)- E:J.eh and every device. approved by the baud
shall be issued :l eenific::l.tc of IOCJtion. Such c:ertificatl::
must be c:onspicuou:s:ly displayed on the dl::viec and can.
uin the (allowing:
(a) Name and address of the hospilJI
(b) Name of lhe registered phJrmacist who is to be
responsible for Slocking the devic::
(c) Location of the device in the hospilJI
(d) MJnufaeturer's naml:: of the devicl:: :lnd the seri:ll
number o( thl:: device.
.
(13) Upon any m:llfunction the device sh::i11 not be
used uncil the m:1[function h:ls been corrected. ,
(14) A copy of this regulJtion shJII be :llUChed to
ceh :lnd every dl::vice certified by the board of ph:!.r.
mJcy. [St:ltutory Authority: RCW 18.64.005. 92-12035 (Order 2778). § 246-369-120. filed 5/28/92. ef.
fective 6/28/92. Statutory AUlhority: RCW 18.64.005
and chJptcr IS.MA RCW. 91-I8~S7 {Order 19[8l.
rl::cOOified as § 246-869-t20, filed 8/30/91, "effective
9/30/91; Regul3tion 47. filed 12/1/65.J
.

expirJtion dJte.
(6) At the time the removal of any drug or medicine
(rom the devic:::, the device shall aUlornaticlly m:lke a
written record showing the name. strength. and quantity
o( the drug or medicine removed. the name of the pa·
tien' r"r whom the drug or medicine was orde~.:d. and
tbe
ntifiC:ltion of the nurse re:r:oving the drug or
m~dicine from the devic::. The record must be main~
uined (or two Ye:lrs by the hospit.:l.l :lnd sh:llJ be acc.:s~
sible to the pharmacist.
(7) Medial practitioners authorized to prescribe.
ph3rmacistS authorized to dispense. or nurses authorized
to administer such drugs shall be the only persons authorized to remove any drug or medicine from the devie:::
and such re:noval by a nurse or medici pr:letitioner
ShOll! be made only pursuant to a chart orde~. An identi·
fiCJ.tion mechanism. r~uired to operate the de',ie::: shall
be issued pemtanently to <::len ope:-J.tor while the operator is on the suff of, or employed by the hospitJI. Such
mechanism must imprint the oper:l!or'9 n:lrne or number
i( it pennits the devie: to ope:-J.te.
(B) The device shall be wl::d only (or the furnishing oj
drugs or medicines for Jdministration in thl:: hospitOlI to
registered in-patients or emergl:::lcy p:ltients in the
baspiul.
1.0) .E)'~....,. hospi\3\ !tcdting apprOY3) to use Jny devie:
lIull. prior to insullJdon of the devie::. register with the
~Jrd by filing an applie:ltion. Such Jp~liCJtion shall
.:::JnIJin: The nJmc and address of the hospu:ll; thl:: nOlme
~{ \lue T'e2islC"Cd prr.rnn:lcist who is to be responsible for
\toc'rin~ fhe device; \ne manu(JCIUrc.r''!l n~me ,Jnd o:OO:J.
,. -\
~ Vfo~~ed loc~lion of e;lcn deVice In

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AbsC\
of a pharmacist. (1)
General. Ph:trm:tceuti=.l services shan be avaihlble on a
24-hour basis. If round-the-clock services of a phanna. _
c:ist arc not fC3siblc:. arrangements shall be made in ad·
vance by the director of pharmacy to provide rC:lSonable
a5Surance of pharmaceutical services.
(2) Access to the pharmacy. Whenever a drug is re·
quired to trC3t an immediate need and not available
from Ooor stock when the pharmacy is closed. the drug
may be obtained from the pharmacy by a designated
registered nurse. who shall be accountable (or bis/her
actions. One registered nurse shall be designated in C3ch
hospital shift for removing drugs from the pharmacy.
(a) The director of pharmacy shall establish written·
policy and recording procedures to assist the registered
nurse who may be designated to remove drugs from the
pharmacy, when a pharmacist is not present. in accord·
anCe with Washington State Pharmacy Practia: Act.
RCW 18.64.255(21, which states that the director o(
pharmacy and the hospital be involved in designating the
nurse.
(b) The stocle conl:liner of the 'drug or similar unit
dose pacbge of the drug removed shall be left with a
copy of the order of the authorized 'practitioner to be
checked by a pharmacist. when the pharmacy reopens,
or as soon as is pr:lctic::lble.
(c) Only a sufficient quantity of drugs shall be re"
moved in order to sustain the patient until the ph:umacy
opens.
(d) All drugs removed shall be completely labeled in
accordance with written policy and procedures. taking
into account sute and federal rules and regulations and
current standards. {Statutory Authority: RCW 18.64.005 and chapter 18.64A RCW. 91-18-05; (Order
191 B). recodified as § 246-873-{)50. filed 8/30/91. ef·
fective 9/30/91. Statutory Authority: RCW
18.64.005(11). 81-16-036 (Order 162). § 360-17-050.
filed 7/29/81.]
. WAC ]46-873-050

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ATrACHMENT
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W It. ~ 246-873-060 Emerzency o,'toalient medicaliors. Xhe direclQr of pharmacy of .
.spital shall. in
concert with thetappropriate committee of the hospital
medical staff, develop policies and procedures. which
shall be implemented. to provide emergency pharmaceuticals to outpatients during hours when normal community or hospital pharmacy services are not available.
T
'clivery of a single dose for immediate administratio.. to the patient shall not be subject to this regubtion.
Such policies shall allow the designated registered
nurse(s) to deliver medications other than controlled
substances, pursuant to the policies and procedures
which shall require that: .
(I) An order of a practitioner authorized to prescribe
a drug is presented. Oral or electronically transmitted
orders must be verified by the prescriber in writing
within 72 hours.
(2) The medication is prepackaged by a pharmacist •
and bas a label that contains:
(a) Name, address, and telephone number of ·the
hospital.
(b) The name of the drug (as required by chapter
246-899 WAC), strength and number of units.
(c) Cautionary information as required for patient
safety and Inform:ltion.
(d) An expiration date after which the patient should
not usc the medication.
(3) No more than a 24-hour supply is provided to the
patient except when the pharmacist has i~form~d appropriate hospital personnel that normal servIces WIll not be
available within 24 hours.
(4) The container is labeled by the designated registered nurse(s) before presenting to the patient and shows
tb • '!lowing:
•• Name of patient;
(b) Directions for usc by the patient;
(c) Date;
(d) Identifying number:
(e) Name of prescribing practitioner:
(f) Initials of the registered nurse;
(5) The original or a direct copy of the order by the
prescriber is retained for verification by the pharmacist
after completion by the: designated registered nurse(s)
and shall bear:
(a) Name and address of patient;
(b) Date of issuance:;
(c) Units issued;
(d) Initials of designated registered ,nurse.
(6) The: medications to be delivered as emergency
pharmaceuticals shall be kept in a secure place in or
ncar the emergency room in such a manner as to pre·
clude the: necessity fllr entry into the pharmacy.
(7) The: procedures outlined in this rule may not be
used for controlled substances except at the following
rural hospitals which met all three of the rural ac=
project criteria on May 17, 1989:

Hospital
I. Late CIIclaa Communit)' Hospital

awn

2. St. JOICph" Hospital

Ocwdah

3. Mitman C4mmllftil)' Hospital

Colru
Da\"Cllpon
Dayton
Ilwaco
Ncwpon
Plitt TOWftJcnd
RiuYt11c
SoulJl Bcad

.c. Uacoln Hospital
5.
6.
7.
I.
9.
10.

DaytClft Oeneral Hospital
Oca" Bach Hospital
Ncwpon Communit)' Hospital
Jcrrcrson Ocncnl Hospital
RiuYtllc Memorial Hospital
Witlapa Harbor Hospital

[Statutory A~thority: Amended effective 6/28/92; St:u.
utory Authonty: RCW 18.64.005 and chapter 18.64A
RCW. 91-18-057 (Order 1918). recodified as § 246873-060, filed 8/30/91. effective 9/30/91. Statutory
Authority: RCW 18.64.005. 89-12-011 (Order 225) §
360-17-055. filed 5/26/89; 83-23-109 (Order 179): §
360-17-055. filed 11/23/83.)
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PHARMACEUTICAL SERVICES - CONTROLLED SUBSTANCES

AUTHORITY: DOP 420.540
PURPOSE: To provide procedures for handling and control "of all controlled substances.
APPLICABILITY: Applies to all wee staff.
DEFINITIONS:
Controlled Substance: A drug substance or immediate precursor of such drug or substance so
designated under or pursuant to Chapter 69.50 RCW. the Uniform Controlled Substance Act.
Resoonsible Pharmacist: A licensed pharmacist placed in charge of a pharmacy" by a
nonlicensed proprietor/owner. Every portion of the establishment coming under the jurisdiction
of the pharmacy laws shall be under "the full and complete control of such responsible
- pharmacist.
.
FIELD INSTRUCTION:
.

.

The Pharmacist SupervisorlResponsible Pharmacist is responsible for all controlled substance.s.
Controlled substances ~tocked within the pharmacy are stored'in a locked cabinet. The cabinet
key is on each pharmacist's key ring. In an emergency, designated medical staff may contact
the pharmacist or pharmacist supervisor in order to facilitate withdrawal of controlled substances
from VaultlPharmacy stock. Controlled substances removed from the pharmacy must be signed
out)n the VaulUPharmacy Contrqlled Substance Log which is also stored in the cabinet.
Withdrawals of controlled substances from the pharmacy must immediat2!Y be entered in the
Medical Room Controlled Substance Log.
.Each receipt of "a controlled substance is immediately documented ;(.1 the VaulUPharmacy
Controlled Substance Log. Documented infonnation includes current date; quantity received;
. Field Order number. current balance; and full signature and title. Per;letual inventory of all
controlled items shall be maintained at all times.
Pharmacy stock of controlled substances is stored in two locations within the institution. These
- locations are: 1) the locked cabinet within the phar:macy and 2) the contPlled sUbstan~ vault
-" located in Major Control. For security reasons, the bulk of all controlled !ubstances within the

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.pHARMACEUTICAL SERVIC;ES • CONTROLLED SUBSTANCES

institution is stored in the vault. Vault storage is inaccessible except to 'the responsible
pharmacist and the Superintenderlt. The SlJPerintendent maintains a duplicate vault
-.
combination in a sealed envelope, pi ainly mark~ and filed in another safe.·

_..

.

Inventories, inspections, searches or shakedowns are never made in the controlled s~bstance
vault or pharmacy locked cabinet ex.cept in the presence of the responsible phannacisl
Once each quarter, the Superintendent or designee appoints a staff member not assianed to
health services to conduct jointly wi,th the responsible pharmacist and the health authority an
inventory of all controlled items. Venn.cation of inventory is d~mented in the Vaultl Pharmacy
Controlled Substance Log indicating date. the word "inventory''. current balance. and signatures
of all members of the inventory team. Discrepancies. if any. are reported to the Superintendent,
Washington State Board of Phannacy, and Drug Enforcement Administration as applicable.
When personnel changes involve t'n~ health authority or responsible pharmacist. a controlled
_ .substance inventory shall be performed ·and all appropriate documentation reviewed. Vault
combinations are changed wneneve.r personnel changes involve the responsible pharmacist or
the Superintendent.
Expenditures of controlled substances from the vault stock is documented in the appropriate
section of the Vault Controlled Substa.1ce Log. Documentation information includes: 1) date;
2) amount withdrawn; 3) current balance.: 4) destination of issue, and 5) full signature and title.
Whenever possible, this procedure is ca'rried out bY the responsible pharmacist.
A working stock of controlled substances ,is held in the locked safe in the Medication Room.
Receipt of controlled substances into this ~itoi:k is entered in the Medication Room Controlled
Substance Log indicating date, time, amo", lOt' received, current balance, source of r.eceipt,
signature, and title. Expenditures of controllea' ~ubstc~.nces from the Medication Rooq1 ~upply
are documented jn the Medication Room Contn.,lIed Substance Log indicating da~e. time.
amount withdrawn, balance. inmate name, inmate 001: number, prescription number).signature,
and title. This documentation is provided for each expenditure from this stock. . .
An inventory of all controlled substances stored in !t.le Medication Room is carried out at the
change of each shift by a 'member of ~e oncomin~l and' offgoing shifts, Each controlled
substance stocked is physically counted. by tablet. cap\sule. milliliter. etc.• and documented in
the Medication Room Controlled Substance Log. Docurri'entation includes date, time, the words
=-. "count correctlcount incorrect", quantity inventoried, and tsign~re of each clinical staff member
_ involved.

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PHARMACEUTICAL SERVICES - CONTROLLED SUBSTANCES

In the absence of the pharmacist. discrepancies that cannot be immediately corrected are
reported in writing by the inventory team to the responsible phannacist. If the responsible
pharmacist is unable to reconcile any discrepancies. a written report is made to the Health Care
Manager. Captain/Shift Lieutenan~ and. if applicable, to the Superintendent. Washington State
Board of Pharmacy. and Drug Enforcet:nent Administration.

PROCEDURE:
RESPONSIBLE PERSON
Re!?ponsible P.harmacist

SEQUENCE
1
2

3

'4
5

6

.-

7

8
9

-

ACTION TAKEN
Stores and· controls all controlled substances
securely.
Maintains documentation of all receipts and
withdrawals of conlroIled sUbstances' «from
pharmacy or vault.
Attends all inventories, inspections, searches or
shakedowns of controlled substance storag~ are~s.
Maintains a working supply of controlled
substances in Medication Room storage cabinet.
Conducts inventory of all controlled substances on
a quarterly basis in conjunction with ·health
authority and apP9inted staff.
Monitors inventory and uses documentation
provided by clinical staff for all controlled
substances stored in the Medication Room.
.Maintains documentation of all receipts and
withdrawals of controlled substances from
Medication Room. .
Documents each withdrawal of controlled
substance from medication Room stock.
Conducts inventory of all controlled substance
steck stored hi the Medication Room at change of
each shift.
.

REVIEW: This field instruction is reviewed annually.

. 1098
ATTACHMENT

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- CONTROLLED SUBSTANCES

REFERENCE:

MSS13.47

SUPERSESSION:

wee 650.570 dated 190ct90
"None

ATTACHMENTS:
'.

GA~Y

-

McCRACKEN, Health Care Manager

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- KURT S. PETERSON. Superintendent

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DATE

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NURSING PROCEDURE.
INPATIENT ORDERS
MEDICATIONS:
1.

Advise the physician/provider that medication orders need to include:
·a.
b.
c.
d.

2.

Date
Time - must have exact time
Controlled substance ordered must also include Form DOC 13-15 .
(This must be identical to the Inpatient order to be valid.)
.
. Exact length of time of the medication being ordered, i.e., 24 hours,
48 hours, 72 hours, 96 hours OR 2 days, 3 day, 7 days (each day equals
24 hours)

Telephone orders must include:

1 a., b., c., d., and Form DOC 13-15. if applicable.
These orders are to be signed as soon as possible.
b~

3.

All orders are to

4.

When transcribing medication orders, the nursing staff will bracket the order with
{} date, time, a clear complete signature and their name stamp on each copy. '

5.

The order must be comoletelv reviewed for completeness and Form 13-15 for
exactness and completion before taking to the Pharmacy.

6.

legibly signed.

If orders are unclear, the nurse attempting to transcribe is responsible for
. retuming the order to the physician/provider for clarity, then delivery them to the
Pliarmacy. .
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NURSING PROCEDURES
MEDICATION RECORD -INPATIENT:

1.

A medication record DOe 13-16 is to be prepared by the nUfsewho transcribes
the first medication order.

2.

This medication ~ecord will contain complete information:
a.
b.
c.
d.
e.

f.
g.

3.

Inmate: Name (Last, first, middle) printed
Facility: wee Inpatient (Ward)
. DOC # clearly printed
Month and year
All allergies are to be printed in red
The name of the nurse who transcribed these orders and prepared this
medication record will be printed ill the lower right corner.
"Name Alert" shall be printed in red directly below the inmate name if the
chart has indica~ed name alert.

Medication: [Rx]
a.
b.
c.
d.
f.
g.
h.

Nams of the medication - both the ordered name and the generic drug
supplied by the pharmacy.
Frequency - i.e., aID, TID, PRN, q 4 hours.
Amount, i.e., 1 tab, 1 cc.
Route of administration, i.e., oral (p.o.), 1M, IV, rectal, etc.
Physic..ian/provider.
Start date and time, if applicable.
End date and time, if applicable.

4.

At the top of DOe 13-16, must have the provider (nurse) name - clearly written'
and initialed.

5.

If the medication is ordered on any other date than the first day of the month,
use a V\~de-top felt marker to draw a line to the correct start date.

6.

If the medication order spans into the next month and space is available on the
medication record, the Rx may be written and labeled with the month (i.e.,
August) in the leff margin. If the record has insufficient space, a new medication
record must be prepared for the following month.

7.

Renewing medication(s) orders, except control1ed substances, may be continued
on the same Rx as the Medication Record if there is no change in dose, " f
frequency or route of administration. This is accomplished by running a redlirle)
through the start and end dates and putting in new dates in red. This also
AlTACHMENT
_
applies to a ~hysician/provide~ change.

1

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PACE-ll.-OF

•
NURSING PROCEDURE
Page Two

MEDICATION RECORD -INPATIENT:
8.

Orders to stop medication or change the order are to be effective immediately.
The medication record will be marked by:
a.
b.
c.

9.

A diagonal line through the Rx box.
.
A wide felt marker line following the last dose given.
Under the wide line. the nurse who transcribed the order will write DC or
change. write their name, date and stamp.

Medication orders that are changing or Discontinuing medications will cau~e the
nurse to return the medication to the pharmacy along with the orders (yellow
. copy of the PER).

10,

Controlled substance changes require the provider to write a ~ order and
DOC 13-15 and a new Rx section on the Medication Record to be completed, as
described in (3 above),

11.

Medication given past the ending time of the order constitutes a medication
error, thus requiring the nurse to complete an incident report with copies to the
nursing supervisor, pharmacy, health care manager and medical records.

12.

Medication(s) that are refused by the patient are to be marked on the medication
record on that dose/time with a red (R). Precharting of medication can
potentially be a liability.

Date

'1102
I.

ATTACHMENT
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DIVISION OF PRISONS

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T1TLE

PHARMACEUTICAL SERVICES - CONTROLLED SUBSTANCES
AUTHORllY: COP 420.540
PURPOSE: To provide procedures for handling and control of all controlled substances.
APPLlCABILllY: Applies to all WCC staff.
DEFINITIONS:
•
Controlled Substance: A drug substance or immediate precursor of such drug or substance so
designated under or pursuant to Chapter 69.50 RCYV. the Uniform Controlled Substance Act.
Responsible Pharmacist: A licensed pharmacist placed in charge of a pharmacy by a
nonlicensed proprietor/owner.
Every portion of the establishment coming under the
jurisdiction of the pharmacy laws shall be under the full and complete control of such
responsible pharmacist.
.
FIELD INSTRUCTION:
The Pharmacist Supervisor/Responsible Pharmacist is responsible for all controlled
substances.
Controlled substances stocked within the pharmacy are stored in a locked cabinet. The
cabinet key is on each pharmacist's key ring. In an emergency, designated medical staff may
contact the pharmacist or pharmacist supervisor in order to facilitate withdrawal of controlled
substances from Vault/Pharmacy stock. Controlled substances removed from the pharmacy
must be signed out in the Vault/Pharmacy Controlled Substance' Log which is also stored in
the cabinet. Withdrawals of controlled substances from the pharmacy must immediately be
entered as a receipt in the appropriate work station Controlled Substance Log.
Each receipt of a controlled substance is immediately documented in the VaultlPhannacy
Controlled Substance Lag. Documented information includes current date; quantity received;
Field Order number, current balance; and full signature and title. Perpetual inventory of all
controlled items shall be maintained at all times.
Pharmacy stock of controlled substances is stored in two locations within the institution.
These locations are: 1) the locked cabinet within the pharmacy and 2) the controlled
substance vault located in Major Control. For security reasons. the bulk of all controlled
substances within the institution is stored in the vault. Vault storage is inaccessible"except to

1.1 WtdAcHMENT
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Oepartment of Corrections
ONISION OF PRISONS

Number
WCC 650.570

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PHARMACEUTICAL SERVICES· CONTROLLED SUBSTANCES
the tvlo institution pharmacists and the Superintendent. The Superintendent maintains a
duplicate vault combination in a sealed envelope, plainly marked, and filed in another s~fe.
Inventories, inspections, searches or shakedowns are never made in the controlled substance
vault or pharma~ locked cabinet except in the presence of the responsible pharmacist.
Once each quarter, the Superintendent or designee appoints a staff member not assianed to
•
health services to conduct jointly with the responsible pharmacist and the health authority an
inventory of all controlled items. Verification of i.!1ventory is documented in the VaulV
Pharmacy Controlled Substance Log indicating date, the word "inventory", current balance,
and signatures of all members of the inventory team. Discrepancies, if any, are reported to
the Superintendent, Washington State Board of Pharmacy, and Drug Enforcement
Administration as applicable. When personnel changes involve the health authority or
responsible pharmacist, a controlled substance inverytory shall be performed and all
appropriate documentation reviewed. Vault combinations are changed whenever personnel
changes involve the responsible pharmacist or the Superintendent.
,

Expenditures of controlled substances from the vault stock are documented in the appropriate
section of the Vault Controlled Substance Log. Documentation information includes:'1) date;
2) amount withdrawn; 3) current balance; 4) destination of issue, and 5) full signature and title.
Whenever possible, this procedure is carried out by the responsible pharmacist.
A working stock of controlled substances is held in a double locked storage in the Medication
Room and in the inpatient workstation (nurs~s S"'l2tion). Receipt of controlled substances into
either stock is entered in the appropriate Controlled Substance Log indicating date, time,
amount received, current balance, source of receipt, signature, and title. Expenditures of
controlled substances frem the Medication Rocl":"l supply are documented in the Medication
Room Controlled Substance Log indicating datE. time. amount withdrawn, balance, inmate
name, inmate DOC number, prescription nUliicer, signature, and title. Expenditures of
controlled substances from the nurses stati::r. supply are documented on the Inpatient
Controlled Substance log indicating time, inr.:ate name, DOC number, provider's name.
dosage, any amount wasted, amount withdra\',~ in the appropriate column and medical staff
person's signature and title. If any quantity of rr-re dose withdrawn is wasted, the destruction
must be witnessed and co-signed by a se-:crlCi medical staff person. Documentation is
provided for each expenditure from Controll:d Substance stock. Except in the case of
extreme emergency, controlled substances sr.ail not be drawn from nurses station stock for
'
.'
outpatient use or from medication room stock fo~ inpatient use.

l.Jr£l&MENT
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Oepel'tment 01 Correclions

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'HCC 650.570
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TITLE

PHARMACEUTICAL SERVICES· CONTROLLED SUBSTANCES
Pharmacy staff monitor controlled substance stock levels in the medication room and
replenish this supply in quantities to meet anticipated/possible requirements. Inpatient nO(sing

staff monitor controlled substance stock levels in the nurses station. New stack or restock
items are requested via a preprinted form which must be signed by two health care providers
and delivered. to the pharmacy. Controlled substance items are supplied in minimum
quantities as indicated on the order form and must be ordered/reordered in those quantities or

multiples thereof. Filled orders for bulk controlled substances are delivered to nurses station
by the pharmacist and receipted for by two health care providers on the order/reorder form.
Order/reorder forms remain a portion of permaner.~ pharmacy .controlled substance records.
Nursing staff are responsible for entering all centralled substance receipts on the controlled
substance log. Such entry includes the time, Ihe statement "from pharmacy" or ather source, if
applicable, the quantity received in Ihe appropriate column and the signature of two medical
staff providers completing the entry.
In some instances, controlled substances may toe stocked in the nursing station which are nol
included on the preprinted inventory listing on L~,e form. In those instances, the drug name
and strength must be entered in a column at l,e top of the page when inilially received in
stock.
A new inpatient unit controlled substance log s;-r:-:t is initiated at midnight and is utilized for a
24 hour period. Utilization of a new form inclu~s completion of the following items: 1) page
number, 2) date, 3) balance brought forward frc,~ the previous 24 hour period at the top of the
page and 4) the signature of the transcriber iil the same block as the wording "balance
brought forward~. At the end of the 24 hour ~od, the ending balance is tabulated at the
bottom of the page. The completed log sh~: is then photocopied and the original form
delivered to pharmacy through the access pc:: in Room 38. The copy is retained in the
nurses siation for a period of 30 days.

An inventory of an controlled subsiances stor;: in the Medication Room and in the nurses
station is carried out at the change of each sh~ by a member of the oncoming and offgoing
shifts. Each controlled substance stocked is v:ysically counted by tablet, capsule, milliliter,
etc., and documented in the Medication Roar.. cr Nurses Station Controlled Substance Log.
Documentation includes date, lime, the Yr-O;--S "count correcUcount incorrect", quantity
inventoried, and signature of each health care p'Iider involved.
Under unusual circumstances, controlled sub~-.ces may be transferred between Medication
Room stock and Nurses Station stock. Sl.C: transfers require two staff persons, one
responsible for each stock, to complete 'the e.~,/ on each log. Entries include dale, time,
Arr.\CI1,\JENT

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Department or Corredions
DIVISION OF PRISONS

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WCC 650.570

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PHARMACEUTICAL SERVICES· CONTROLLED SUBSTANCES
"transferred to" or "received from" (indicating Medication Room or Nurses Station), the quantity
of cOntrolled substance transferred and the signature of each staff person on each log.
Transfers from one stoel< are immediately listed as receipts in the receiving inventory. In
addition, when controlled substances are transferred between working stocks, phannacy is
notified immediately by memo indicating drugs transferred, source and destination, and the
reason necessitating the transfer.
In the absence of the pharmacist, discrepancies that cannot be immediately correded are
reported in writing by the inventory team to the responsible pharmacist. 'If the responsible
pharmacist is unable to reconcile any discrepancies, a written report is made to the Health
Care Manager, Captain/Shift Lieutenant, and, if applicable, to the Superintendent,
Washington State Board of Pharmacy, and Drug Enforcement Administration.
Attached are general controlled substance handling procedures for inpatient nursing and
outpatient nursing staff.
. .;
PROCEDURE:
RESPONSIBLE PERSON
Responsible Pharmacist

SEQUENCE
1
2

3

4

S

6

ACTION TAKEN
Stores and controls all controlled substances
securely.
Maintains documentation of all receipts and
withdrawals of controlled substances from
pharmacy or vault.
Attends all inventories, inspections, searches or
shakedowns of controlled substance .~storage
Ereas.
Maintains a working supply of controlled
siJbstances in Medication Room storage
cabinet.
Provides
working
supply of
controlled
siJbstances for nursing station stock upon
proper request.
Conducts inventory of all controlled substances
en a quarterly basis in conjunction with health
cuthority and appointed staff.

- 110..G-rACHMENT__(_
PACE

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PHARMACEUTICAL SERVICES· CONTROLLED SUBSTANCES
Monitors inventory and uses documentation
provided by clinical staff for all controlled
substances provided from Medication Room and
Nurses Station stock.
Maintains documentation of all reCeipts and
withdrawals of controlled substances from
Medication Room and Nurses Station. -

7

8

Nursing StafflMedical Provider

9

Documents each withdrawal and receipt, if
applicable, of controlled substance' from
Medication Room or Nurses Station stock.
Conducts inventory of all controlled substance
stock stored in the Medication Room and
Nurses Station at change of each shift. "-~.

10

REVIEW: This field instruction is reviewed annually.
REFERENCE:

MSS13.47

SUPERSESSION:

WCC 650.570 dated 9Mar95

ATTACHMENTS:

GARY McCRACKEN, Health Care Manager

. DATE

PHIL STANLEY. Superintendent

DATE

ANDREA BYNUM, Command Manager

DATE

GS:cn

7'ACHMENT_....:J__1

110pAGE 10J

OF

I Cl

CONTF

lEO SUBSTANCES HANOUNG PROCEl
NURSING STATION MEDICAL STAFF

<ES FOR

1.

Controlled substances are to be signed out in single dose increments only.

2.

Once signed out of working stock, controlled substances are to be administered immediately.

3.

Controlled substances designated on an "as needed" basis are not to be signed out based on anticipated need
but on afrequency no oftener than specified by the practitioner's order and then only if requested by the inmate.

4.

The staff member signing out the controlled subslance must be the individual who administers the medications.

5. Verify the inmate's identity prior to controlled substance administraUon.
6.

The staff member administering an oral controlled subslance is responsible for ensuring the medication has not
been cheeked, palmed or otherwise concealed.

7.

The staff member administering any conlron~d substance is responsible for documentation of administration on
the medication administration record and in the nursing notes, if appficable.

8.

The sign-out entry in the controlled substance log will include.; 1) date, 2} time (in 2400 hour format), 3) inmate
name Qast name and first initial or first name), 4) inmate DOC number, 5) name of provider, 6) dose, 7) quantity
wasted, if any, 8) quantity checked out [In arabic numerals only), 9) balance, and 10} full legible signature(s)
and tiUe(s}.

9.

Any error made on the controlled substance sign out sheet will be justiftedl explained on the reverse side of the
page by the staff member making the error. If that staff member not in the facility, the explanation is made by
the staff member discovering the error if possible. i.e., math error, wrong sheet, etc.

is

10. Disposal of unused or partially used controlled substance shall be witnessed by two medical staff members and
attested to by the same with their signatures on the s:~n out sheel Abrief explanation for the destruction is to
be documented on the back of the sign out sheet

11. If the required dose of an injectable controlled SU:S:E::CS is less than that contained in the syringe, the quantity
to be wasted/destroyed will be expelled in the pr;:;::;:; of awitness utilizing guideline #10 and the remainder
then administered to the patienl

12. When conducting controlled substance invemar1 :::::::;3,. each staff member must witness the actual count
and the documentation of the count in the control:;~ 5:'::SLance log for accuracy prior to signing each document.
The staff member conducting the actual count stc!..'!: ::c: Know the quantity of controlled substance indicated in
the controlled substance log.

13. If partial tablets are found in working stock wh:c:: :i: ;;!ii~entifiable, notify the pharmacist who will assist with
disposal.

14. If a seal is broken on an injectable controllsd s!.!t~~.::= i:-i:ld in working stock, the drug should be held in
working stock until destruction/disposal by apprc-cnE: ~jjannacy staff can be completed.

1 .1 08

15. If an error is made when making an entry in the c:r.:-~ substance 109, draw a sinole line through that pornon
of the entry in error and make and initial the corre::i:.:,_ Tne portion of the ~ntry in efTor must remain legible.
1

1__
lOY OF \ C' L

ATTACHMENT_ _
PACE

•

CONTROL~

.&J SUBSTANCES HANDLING

PRu~EOURES

Fkl¥ACHMENT

OUTPATIENT NURSING STAFF
PACE

105'

--OF

-4-.c;. l

Controlled substances are to be signed out in single dose increments only.
Once signed out of working stock. controlled substances must be administered at the
or ·refusals".
next medication line except in the cases of ·no shows·
.

.

The staff member signing out the controlled substance must be the individual who
administers the medications.
Verify the inmate's identity prior to controlled substance administration.
The staff member administering an oral controlled substance is responsible to ensure
to the greatest extent possible that medication has not been cheeked, palmed or·
otherwise concealed.
'.

The staff member administering any controlled substance is responsible for
documentation of administration on the medication administration record. •
The sign-out entry in the controlled substance log will include: 1) date. 2) lime' (in
2400 hour format), 3) quantity checked out (in arabic numerals only), 4) balance
(which must be verified after each entry), 5) inmate name (last name and first initial or
first name), 6) inmate DOC number, 7) prescription number if available and 8) full
legible signature and title.

l.

Any error made on the controlled substance sign out sheet will be justifiedl explained
on the reverse side of the page by the staff member making the error. If that staff
member is not in the facility, the explanation is made by the staff member discovering
the error if possible, Le., math error, wrong sheet, etc.

I.

Disposal of unused or partially used ::ontrolled substance shall be witnes.sed by two
medical staff members and attested iJ by the same with their signatures on the back
of the sign out sheet. A brief explanation of the reason for destruction must preceded
their signatures.
"..

10.

When conducting controlled substa:-:s inventory ~:ounts). each staff me'mber mus~
witness the actual count and tne oc:.;mentation 0: tne count in the controlled
substance log for accuracy prior to s.~ning each cocument. The staff memb~r
conducting the actual count shoulc :-.:t know the quantity of controlled substance
indicated in the controlled substanc; log.

11.

If partial tablets are found in wor.<inf s~ock which are unidentifiable, notify the
pharmacist who will assist with dispcsal.
.
•.

12.

If a seal is broken on an injectable c:r.irolled subsiance held in working stock, the
drug should be held in working stoc~: ..:ntil destruct!on/disposal by appropriate
pharmacy staff can be completed.

13.

If an error is made when making an :mry in the controlled substance log, draw a
sinale line through that portion qf trr: entry in error and make and initial the correction.

;

The portion of the entry in error mus: remain legible.

1109

.

NURSES STATION
DATE:

Cl.1l~TROLLED SUBSTANCE

_-------4

SUPPLY
on hand

(PHONE ORDERS WILL NOT BE ACCEPTED)
DESCRIPTION

QUANTlTY
REQUESTED

ORDER FORM

MINIMUM
QUANTITY

PHARMACY
Qt sent & Lot #

ORAL
Acetaminophen/codeine 30 mg

20
25
20
10
25

Clonazepam 1 mg
Diazepam 5 mg
Lorazepam 1 mg
Methadone 10 mg
MS Conlin 15 mg

25
25

MS Contin 30 mg
MS Contin 60 mg

25

Oxycodon~ APAP

25

5/325
Pentazocine/Naloxone 50/.5
Phenobarbital 30 mg

25
10

Other
Other

INJECTABLE
Diazepam 10 mgl2 m[

.

1

Lorazepam 2 mg/ml1 ml (Refrigerate)
Meperidine 50 mg Inj.
Meperidine peA

5

10
1
10

Morphine 10 mg Inj.

1

Morphine PCA
Other
Other

.

.
SIGNATURE OF TWO ORDERING HEAtTH CARE PROVIDERS:

Requesting

Co-Signature
SIGNATURE OF PHARMACIST FlUNG ORDER:

Signature of Pharmacist

Date Filled

SIGNATURE OF TWO RECEIV1HG HEALTH CARE PROVIDERS:

1110
Signature/Daterrime

Signature/DatefTime

AlTACHMENT
. PACE

/o\..,

1
OF~

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INTRODUCTION

I.

• Provide for restitution;

r·

• Be accountable to the citizens of the state;

I·
i! ~.'

• Meet the national standards appropriate to the Slate of Washington.

CODE OF EnneS
High moral and ethical standards among correctional employees are
essential for the success of the department's programs. The Department of Corrections subscribes to a code of unfailing honesty,
respect for ~ignity and individuality of human beings, and a commitment to professional and compassionate service.

Be. ":.
~

DEPARTMENT EXPECTAnONS

'"

J

•

As a new employee of the <!:partment, you will have many things to
learn, not the least of which will be the expectations of your supervisor, your co-workers. and the agency as a whole. To assist you with
this responsibility. following is a list of some departmental expectations for your study. Familiarize yourself with the list so that you
may understand and fulfill the duties of your position.

·,· .'

As a representative of the Department of Corrections, you will be
expected to:
• Positively represent Washington State government to everyone you
meeL You are our best public relations agent;
• Dress appropriately for your job classification and duties. Oothing
may not have mottos. logos, or advertisements that may be offensive or in conflict with the goals of the Deparunent;
• Wear. issued unifonns only as authorized:

• Treat fellow staff with dignity and respect;
• Be impartial, understanding and respectful to offenders;
;

.'

.

!

i!
I

• Be a good citizen, obey laws while on and off-duty. Your conduct
off duty may reflect on your fitness for duty;

.'
".-; '.

I

• Serve each offender with appropriate concern for their welfare and
with no purpose of personal gain;

•

I

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....""-"'"-

EMPLOYEE HANDBOOK'
• Rep?rt all personal contact from offenders. their families. or
known associarcs. outside your job in accordance with department
procedures;

.. -:

• Report through the proper chain of command any corrupt or
unethical behavior which could affect an offender or the
department's integrity;
• Remain constantly alert in all situations;
• Custody staff: remain at your job/post until properly relieved;
• Let your supervi~or know about any personal. emergency use of
equipment or phones;

-.

• Obtain appropriate permission before removing any state property
from state premises;
~

...... ,.

'. :..... :~-

-

0".

~

• Conduct yourself and perform your duties safely;
• Smoke only in designated smoking areas.
It is also important as a new employee. that you understand some of
the specific prohibitions that the department must enforce. You are
not allowed to:
• Discriminate against any offender, employee, prospective employee, or volunteer on the basis of race. color. religion. gender.
sexual orientation. age. creed, national origin, marital status,
veteran status or disability;
• Use profanity or inflammatory remarks with offenders or individuals with whom you work;
• Report to work under the influence of alcohol or drugs; .
• Traffic or bring any article of contraband into an institution,
facility or office;
.' ......: .. :.

• Barter or make personal deals with offenders. offender families or
visitors;
• Engage in personal relationships with offenders. their family
members. or close personal associates;

tJ .. .

.

'.'

•

1112

J-

ATrACHMENT
PAGE

1:-

OF

~

'. ~

f

•

Department of Corrections

No.

PERSONNEL SERVICES

. Effective Date:

Page 101
Subject:

854.075

July 1, 1983
2

. EMPLOYEE RELATIONSHIPS WITH DEPARTMENT OF
CORRECTIONS OFFENDERS

Objective:
.
To provide guidelines to ensure that employee relationships with offenders
are maintained in a professional manner.
Policy:
Relationships with offenders must be conducted in a manner consistent ,with
state law and prudent correctional practice. Employees are expected to manage
their relations with offenqers in a professIonal manner at all times and· to
treat offenders with respect and dignity.
1.

Favorit ism: Staff must recognize the individuality of offenders without
favoritism •. Such.conduct is inherently unfair to both the favored and the
nonfavored. Conversely, grudge holding, bias. or unwarranted negativism
toward or regardi~ an offender is to be avoided. Professional reaction
to offenders must always be' objective and not"based on personal or subjective issues.
-

2.

Association with Offenders: Association with DOC offenders is to be
avoided in the interest of professional unbiased service. Unofficial·
contacts with knomn offenders under the jurisdiction of DOC are to·be
reported by emplo,ees. to thei'r supervisors on' form DOC 3-39(X). This
does not include casual, unintentional and unsubstanrive contacts. '.
Personal communications and/or relationships between employees and
offenders are not appropriate and are prohibited.

3.

Traf ficking: Without specific writ ten approval of the appoint ing '. ,,'
authority, no employee may give or accept gifts, gratuities or favors,
have any barter or financial dealings with 4n offender, an offender's
family or agent. "Gratuit ies" include any form of property or services.

4.

l-lessages and Art ides of Property: Employees lIay engage in the t:-ansmil=··
sion of messages, mail, or articles of property only as part of their
authorized duties.
ATIACHMENT

113,3

_

PAGE---.l-OF.--:;5

_

"

.

,

POLICY·\.
DIRECTIVE
Department of Corrections

No"

....J'_

Pago _ _

01

2_ _

S.

Writs and Pc titions: Without specific approval from the appointing ;luthor ity.
employees nrc not to.dsulGt. ad"ioe. or counsel offender9 In"the'prcpl1rntion of writs, appeals. or petitions for exe~utive clemency or other legnl "
concerns of simirar nature. Eusployee!J may refe'i- of fendera to the DPP~O­
pria.te leZQl service agencY,dr person:; fur assistance in tltr.llC matters." ;'-

6.

Offender Sponsorship: Em'ployces are not to serve
lnmnteB or work/training residents;

DS

furlough sponsors _~or .

'-...-.

Exc e l,t4:ons to this policy require t"tle written perm.t~sion from the Sc:crctary, .
or his designee.
. -:,'.
... .•~ ....
.
::::::~.~Supersession:
.. -.... '.
Policy Directive 651.005. Eml;loyee Rela ttonships with Dcpnrtmcl\t of Corrcd~iolts
Offenders. May r. 1982.
I.
I.
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and understand the contents of this Policy Dir'ective •

.. \::: .'
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Approyod. Socrclnrv 01

d

COffCCIiOn!l@~

'1

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,
DEPARTMENT OF CORRECTIONS t

REPORT O~ CONTACT WITH A D.O.C. OFFENDER

...10.1£

CMSIOH OR OfFIce

.lISnlUnOH CR RliCllOH

J08 n1\Ji IW\TH D.O.!=-I

PURSUANT TO THE REQUIREMENTS OF DOC POUCY DIREcnVE 854.075, REGARDING EMPl.OYEE RELATIONSHIPS Willi D.O.C. OFfENDERS,
nilS IS TO REPORTniATl HAD niE FOLLOWING CONTACT:
'.'t; :
l.CCAlIOH CI' CClUAet

HAMS OF O'nlE!\ OFFeJoiOER OR lOamfYIHQ FV.TUAe

I

I

1

I

C£SCIUI'lICN QlI CONTACT

LEHGnt Of CQlItACt

.
.

DAtE 01' CQH1'ACT

.

.,·'REPORT REV1EWED BY:
SUPERVISOR

...

DATe 01' IlUORT

EMJ",0'tU'S SIlJNA11JRl!

nn.e

1

DATe

1

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CCHTACTWA$:.

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SIQHFlCAHT
NONSlC1NlFICM.-

\

I

SUPERINTENDENTJREGIONAL ADMINISTRATOR/COMMUNITY RESIDENTIAL AREA ADMINISTRATOR OR DMStON DIRECTOR OR OFFICE CHI:i=
IF IN HEAOQUARTERS:
.
.
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SlQHATIJAC

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ATTACHMENT_ _
PAGE

]

OF

'3

•

ALLEN, GEORGE

.
Employee Name (please Print)

ACKNOWLEDGEMENT OF RECEIPT OF
DOC EMPLOYEE HANDBOOK

• • • '!;'!. •••

-

..
I acknowledge receipt of the June 1993 W~shington
State Dep3rt;inent
,.
. of Corrections Employee Handbook and agree to become familiar
with and have a thorough knowledge and understanding of the':.t:·
contents.
.
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Original - Personnel File

.

....

'

1116

ij

ATTACHMENT
PACE

I

.

OF

I,

 

 

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