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Based on observation, review of hospital policy, and staff interview, the facility failed to ensure 1 of 3 anesthesia drug carts containing controlled anesthesia medications was locked and/or supervised in the department of surgery. This has the potential to impact all surgical patients if the medications in the unsecured cart were altered or missing when needed. The facility averages 71.5 surgeries per month.

Findings are:

A. Review of the surgical services for the facility began at 1:35 PM on 6/15/15 with the Surgery Manager. All of the surgeries scheduled for this day were completed with no patients remaining in the department. The Surgery Manager stated they have 3 anesthesia carts in the department (1 in each of the 2 operating rooms and 1 in the procedure room). Tour of the operating and procedure rooms began with Operating Room 1 (OR 1) at 2:55 PM. Tour and observation of OR 1 found it was clean and empty of surgery staff. The Surgery Manager was observed walking to the anesthesia cart and she pulled on the medication drawer. The drawer pulled open. The Surgery Manager verbalized surprise as no surgery staff was in the OR 1 room or outside the OR in the surrounding area. The medication drawer contained multiple vials of each of the following scheduled/controlled medications:
- Propofol is used to induce or maintain anesthesia during certain types of surgical procedures, it slows the activity of the brain and nervous system causing relaxation and sedation
- Versed used as a sedative at the beginning of surgery and during surgery in some cases (a benzodiazepine) often given with Fentanyl for anesthesia
- Fentanyl used for pain and for anesthesia and is a narcotic/opioid drug
- Epinephrine used for allergic reactions and life threatening cardiac events
- Toradol used for moderately severe pain and is an anti inflammatory drug
- Reglan used for heartburn and reflux, will lessen nausea following surgery
- Zofran used to prevent nausea and vomiting following surgery

B. On 6/15/15 at 2:55 PM in an interview, the Surgery Manager confirmed that the anesthesia cart must be locked unless supervised and attended by authorized personnel. She said the last case of surgery for the day had ended at 12 Noon, almost 3 hours before entering the room.

C. An interview with the anesthesia provider (a Certified Nurse Anesthetist or CRNA) was completed on 6/15/15 at 3:25 PM. The CRNA confirmed she was not in OR 1 or in the area outside the OR 1 room. She also confirmed the anesthesia cart had been left unlocked while she left the area to obtain some medications from the pharmacy. She acknowledged that the anesthesia carts are required to be locked when no authorized staff is present.

D. Review of the facility's policy and procedure titled "SECURITY OF MEDICATIONS-ANESTHESIA CARTS" was provided by the Vice President of Clinical Services. The policy directs "Scheduled drugs (schedule class II, III, IV, and V) shall be locked within a secure area." Further in the policy, it directs "When the operating room is not in use (i.e., after hours, weekends, holidays), scheduled drugs (schedule class II, III, IV, and V) must be locked within a secured area. This may be accomplished by the following:" "Locking the entire surgical suite", "Locking non-mobile carts containing drugs and biologicals and, locking the room where the non-mobile cart is located", "Locking mobile carts containing drugs and biologicals within a locked room", or "Otherwise locking drugs and biologicals within a secure area". The policy ends with the statement "All scheduled substances must be locked within a secure area regardless of whether a patient care area is staffed or actively providing patient care."

Based on record review, discharge planning policy review and administrative interview, the facility failed to have a discharge summary that included the required recapitulation of the residents' stay for 2 (Residents 34 and 35) of 2 Swing Bed residents who were discharged. The facility also failed to ensure 1 (Resident 34) of 1 Swing Bed discharged residents had included in the resident's discharge instructions the outpatient therapy services ordered by the physician. The total Swing Bed sample was 5. The Swing Bed census was 3 on entrance 6/15/15. This finding has the potential to affect all Swing Bed residents at discharge.
Findings are:

A. Record review done on the closed record for Resident 34 revealed a Swing Bed hospital stay from 4/2/15 until 4/14/15. The Admission CPOE (Computer Physician Order Entry) report dated 4/2/15 lists diagnoses of Atrial Fibrillation (irregular heart beat), CAP (Community Acquired Pneumonia), Chronic Kidney Disease, Congestive Heart Failure and Diabetes. The resident discharged on 4/2/15 to home. The record failed to have documentation of a recapitulation of the resident's stay.

Record review of the discharge CPOE report dated 4/14/15 at 11:21 AM orders follow up post discharge Outpatient Physical Therapy (PT) and Speech Therapy (ST). Review of the facility document titled "Patient Discharge Instructions" dated 4/14/15 at 11:25 AM revealed the staff failed to ensure Resident 34's instructions included the Outpatient PT and ST as ordered. Interview with the Director of Nursing (DON) 6/16/15 at 2:05 PM confirmed this finding.

B. Record review done on the closed record for Resident 35 revealed a Swing Bed hospital stay from 4/2/15 until 4/20/15. Review of admission orders dated 4/2/15 identified the resident was admitted post acute hospital stay for bilateral knee replacement. The resident discharged on 4/20/15 to a Skilled Nursing Facility. The record failed to have documentation of a recapitulation of the resident's stay.

C. Record review of facility nursing department policy titled "Discharge Planning" last updated 12/13 states that "Each patient should have an individualized discharge plan that is accurate, comprehensive and ongoing." Under "Procedure #6" the policy states "Patients will receive written instructions consistent with the attending physician's orders prior to discharge." The policy does not mention documenting a recapitulation of the patient's stay in the medical record.

D. Administrative interview with the DON on 6/16/15 at 1:30 PM confirmed Residents 34 and 35 did not have documentation of a recapitulation of the residents' stay. The DON stated the facility does not complete a document which includes the recapitulation of the residents' Swing Bed stay at discharge. The DON further confirmed the facility does not have a policy which requires this documentation.