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Based on observation, interview, and record review, the hospital failed to ensure biologicals and drugs were not expired and correctly labeled in the emergency department, pharmacy and patient care area.

Findings include:

Observation 8/08/12 during initial tour from 11 A.M. to 14:30 P.M. revealed the following expired supplies:

EMERGENCY DEPARTMENT:

Medication Storage Area:
12- single use individual dosage Xopenex 0.63 milligrams (used to prevent or relieve the wheezing, difficulty breathing, and chest tightness caused by lung disease. Exp. 6-12
1- Vial Depro-medrol (medication used to treat certain allergies, skin conditions, and arthritis), vial found to be opened and unlabeled. Lot # OBXRX, Exp. 12/2012.

Observation and tour of the Pharmacy at 11:40 AM on August 9th, 2012 along with Pharmacy Technician, Employee ID # 52 revealed the following expired medications:
5 - Vials Vancomycin 1 Gram medication for Intravenous Administration. Lot # 96025DD, Exp. 06/2012.

Interview with Pharmacy Technician Employee ID # 52 revealed: All pharmacy stock is checked monthly for expired drugs and labeled with expiration date. Employee ID # 52 stated, "I must of missed it, I even had someone double check me and they missed it to."






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Observation on 08-08-12 at 11:30 a.m in the medication area between ER Treatment Rooms 1 and 2 revealed the following:

Three (3) vials ( 1 milliliter {ml} dose) of Narcan 0.4 milligram (mg)/ ml expired June 2012.

One (1) large bottle of liquid Prednisone 15 mg/ ml had spilled into the drawer of the plastic medication chest.


Observation on 08-08-12 at 11:40 a.m in Trauma Room revealed the following:

One (1) 1,000 ml of D5 W intravenous (IV) fluid that expired July 2012.

Two (2) Petrolatum gauze non-adhering dressings( expired May 2012.

Observation on 08-08-12 at 11:40 a.m in the medication refrigerator at the nurse's station revealed: one opened vial of Novolog 70/30 insulin that was dated 05-08-12. Interview with RN #58, she stated insulin was good for 30 days after opening. She acknowledged the insulin was expired and discarded it.

Review of Novolg manufacturer's instructions read to "...store in refrigerator or at room temperature for up to 28 days. Throw away an opened vial after 28 days of use even if there is insulin left in it..."

Review of facility policy titled "Policy For Multi-Dose Vials," undated, read: "...Multiple dose vials that contain preservative maybe kept for a period of 30 days or until the expiration date, which ever comes first..."

Review of Winnie Community Hospital Policy and Procedure IX.9 titled "Expiration Date Control" states "A system has been developed to prevent pharmacy personnel or nursing personnel from using drugs which have expired. This procedure will facilitate the expedient removal of expired drugs from hospital inventories..."

Review of Pharmacy Department form "Pharmacy/Nursing Survey Form" at 13:00 PM on August 10th, 2012 revealed: Completed audit forms for June and July 2012 indicating expired and outdated drugs were checked along with labeling and dates of open medication through out the hospital.

Based on observation, interview, and record review, the hospital failed to ensure supplies were not expired in the emergency department and laboratory.

Findings include:

Observation 8/08/12 during initial tour from 11 AM to 14:30 PM along with Directory of Nursing Employee ID # 51 revealed the following expired supplies:

Laboratory Area:
3-23 gauge 1 inch BD Safety glide needles. Lot # 7198161, Exp. 2012-07
5-Vacutainer Blue 2.7 milliliter test tubes. Lot # 1178308, Exp. 07-2012
1- Box of 10 Ammonia Inhalants. Lot # 3307A, Exp. 12-20-2011

Emergency Trauma Room:
1- Quicktrach Emergency device - Pediatric, 2.0 millimeters. Lot # 17108, Exp. 2010/12
2- Thoracentesis/Paracentesis tray. Lot X L9D309F, Exp. 2011/12
2-Adult/Pediatric Chest Tube Drainage Unit. Lot # 88993-1, Exp 2011/11
1-Lumbar Puncture Tray 20 ga x 3 1/2 in Spinal Needle. Lot # L9D30D, Exp. 2011/07
8-Silver Diaphoretic Adult ECG-electrodes. Lot # 0804031. Exp. 2010-04

Interview with Lab Supervisor Employee ID # 55 at 11:20 AM on August 8, 2012 in the Lab area revealed: Employee # 55 stated that she was unaware of any expired blood tubes and was also unaware of the box the of ammonia inhalants in the lab area. Employee # 55 stated all the expired blood tubes should be and the ammonia inhalants should be thrown away if they are past the expiration date.


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Observation on 08-08-12 at 11:40 a.m in the Trauma Room revealed the following:

Three (3) Incision & Dranage (I & D ) Kits, all 3 expired April 2012.

Glucometer Control Solution (low) was opened and not dated. According to the manufacturer's instructions: "discard the solution after 90 days after opening."

Interview with Employee ID # 51 the morning of 08/08/2012 revealed: Outdated supplies should not be available for use and should of been pulled from stock. Employee further stated that all supplies should be checked monthly for expiration dates and pulled if expired.

Based on observation and interview, the housekeeping department failed to esnure the facility was kept clean with supplies stored in proper places.

Findings include:

Nursing Unit: Linen Closet:

Observation on 08-08-12 at 11:40 a.m. of the "Linen Storage" closet revealed uncovered linen stored on open shelves. Further observation revealed a " sticky pest strip" pad located on the floor in the coroner of the room. The sticky pad contained multiple roaches and other debris. The floor had grime and dirt; a used exam glove was obseved on the floor.

Interview on 08-10-12 at 12:15 p.m. with the Housekeeping Supervisor ( ID # 61) he stated it was Housekeeping's repsonsibility to make sure the linen closet was cleaned. He went on to say it should be done every day.

ER # 1

Observation on 08-08-12 at 11:25 a.m in ER # 1 revealed clean uncovered linen stored on two open shelves. The shelevs were located in close proximity to the patient stretcher. Interview at this same time with the Director of Nurses (DON) she acknowledged it was possible for the linen to become contaminated between patients and it was an infection control issue.

Based on interview and record review, the facility failed to follow its policy regarding "Do Not Resuscitate Orders" for one (Patient ID # 6) of 5 sampled in-patients.

Findings include:

Review of the clinical record of Patient # 6 revealed he was 79 years old and admitted to the facility from a Nursing Home on 08-08-12 with diagnoses of Chronic Obstructive Pulmonary Disease ( COPD) Exacerbation, dyspnea, and hypoxia.

Record review on 08-10-12 at 10 a.m. revealed an orange sticker on the front of Patient # 6 ' s medical record.

Further review of the record revealed a physician ' s order dated 08-08-12 titled " Physician Orders For Code Status. " The order contained circled " NO " : for Cardiopulmonary Resuscitation (CPR) , intubation, and defibrillation. " Attached to this page was a second page titled " Consent for Do not Resuscitate, " : that contained signature lines for the patient and or family to consent for a DNR status. The signature lines were blank on the form in Patient #6 ' s medical record.

Interview at this same time with LVN # 68, she stated " Patient # 6 is considered a full code at this time because his family has not signed the consent. " The DON entered the nurse ' s station at this time and said according to orange DNR sticker and the physician ' s order Patient # 6 was a " Do Not Resuscitate. "

Review of the facility policy titled " Do not Resuscitate (DNR) Orders " , undated, specified the physician ' s order should be completed and " 5. The patient and/or medical power of Attorney and/or appropriate authorized family member (if patient unable to sign) will need to complete the Consent for DNR, which will be placed in the patient ' s medical records. 6. The nurse will then label the font of the patient ' s chart with an orange sticker indicating DNR ... "

Based on record review in interview, the facility failed to ensure that a current care plan was developed for 3 (Patient ID # 6, 7, 8) of five (5) sampled in-patients.

Findings include:

Patient # 6:

Review of the clinical record of Patient # 6 revealed he was 79 years old and admitted to the facility from a Nursing Home on 08-08-12 with diagnoses of Chronic Obstructive Pulmonary Disease (COPD) Exacerbation, dyspnea, and hypoxia.

Interview on 08-10-12 at 11 a.m, she stated Patient # 6 was alert but confused and had low oxygen saturation levels on admission. She went on to say he was currently receiving oxygen at 4 liters per minute.

Continued review at this same time of Patient # 6 ' s care plan revealed " Discharge Care Plan, " dated 08-07-12 . The DON said this is a plan initiated in the ER for all patients. " Patient # 6 ' s care plan should have been updated to include his specific respiratory issues. "

Patient # 7:

Review of the clinical record of Patient # 7 revealed he was 79 years old and admitted to the facility from a Nursing Home on 08-05-12 with diagnoses of abdominal Pain and Nausea and Vomiting.

Interview on 08-10-12 at 11 a.m, she stated Patient #76 had a long history of dehydration and abdominal pain. He currently lived with his 2 sons bit the environment was not good for him,. All three ( 3) have history of severe alcohol abuse. The facility was working on getting him a place at a nursing home.

Review of Patient # 7 ' s " Comprehensive Pain Assessment, dated 08-05-12 revealed he rated his abdominal pain at a 6 on a scale of 10 and that he was nauseated.

Continued review at this same time of Patient # 7 ' s care plan revealed " Discharge Care Plan, " dated 08-07-12. The DON said this is a plan initiated in the ER for all patients. " Patient # 7 ' s care plan should have been updated to include his specific pain and nausea issues.

Patient # 8:

Review of the clinical record of Patient # 8 revealed he was 82 years old and admitted to the facility from a nursing home on 08-09-12 with diagnoses of Cystitis and Urinary Tract Infection (UTI)..

Interview on 08-10-12 at 11 a.m, she stated Patient #8 had a long history of UTIs and had a ureteral tear at his meatus. In addition, he has a indwelling catheter and received " bladder washes " with antibiotics.

Continued review at this same time of Patient # 8 ' s care plan revealed " Discharge Care Plan, " dated 08-07-12. The DON said this is a plan initiated in the ER for all patients. " Patient # 8 ' s care plan should have been updated to include his specific infection and indwelling catheter issues.

The DON went on to say her expectation was that all care plans should be updated and individualized within 24 hours of patient admission.

Review of the facility policy titled " Care Plans, " undated " read: " care plans are to be implemented on admission into the hospital ...these should be personalized to each patient ' s needs ... "