HospitalInspections.org

Based upon onsite observation and document review by Life Safety Code (LSC) surveyors on 10/13/2016, the facility does not comply with the applicable provisions of the 2012 edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated 10/13/2016 for Life Safety Code:

K-0015
K-0025
K-0029
K-0045
K-0063
K-0067
K-0147
K-0155

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on 10/13/16, the facility does not comply with the applicable provisions of the 2012 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated 10/13/16 for Life Safety Code.

K-0015
K-0025
K-0029
K-0045
K-0063
K-0067
K-0147
K-0155

Based on observation, interview and policy review the facility failed to ensure that medications removed from their original containers were labeled and stored securely for one of one (patient #5) surgical procedures observed. Findings include:

On 10/11/2016 at 1200 during observation of a surgical procedure for patient #5 the certified registered nurse anesthetist (CRNA) was observed to have 4 syringes of a milky white substance laying on top of the anesthesia cart (2-30 cc syringes and 2- 10 cc syringes). She picked up one 30 cc syringe and placed it in her shirt pocket, placed the other 30 cc syringe and the 2- 10 cc syringes in the top drawer and left the room. When the drawer was checked while the CRNA was out of the room it was found to be unlocked and the syringes were not labeled. This was confirmed in the company of staff N, the operating room manager, at the time of observation.

On 10/11/2016 at 1215 when queried as to this practice, staff N stated "the CRNA has been educated to label the syringes and lock the medication cart."

On 10/12/2016 at 1000 the policy BLH ANES 07-02 titled "Medication Labeling" revised date 07/26/2016 was reviewed. Under "guidelines: ...II. Labeling occurs when any medication or solution is transferred from the original packaging to another container..."
On 10/12/2016 at 1015 the policy BLH PH M-006 titled "Medication Storage and Security" revised date 06/2016 was reviewed. On page 2 of 3 under "3. Security of Medications...C. Medication Preparation and storage ares shall be locked storage areas, locked medication carts, or in an area of constant surveillance to prevent unauthorized access..."