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Based on review of Medical Staff Rules and Regulations and review of medical records, the hospital failed to ensure that all history and physical exams performed on surgery patients prior to admission are updated within 24 hours of admission or prior to surgery.

Findings include:

1. Fifteen (15) discharged medical records were selected at random from a list of discharges from 02/14/11 through 04/15/11, and reviewed along with 10 current inpatient medical records for a total of 25 medical records. Nine (9) outpatient surgical records from 05/05/11 through 05/11/11 were also reviewed.

2. On four (4) of nine (9) outpatient surgery records reviewed and on one (1) of one (1) inpatient surgery record reviewed, the history and physical exam had been performed anywhere from three (3) weeks to five (5) days prior to admission, but had not been updated at the time of admission or prior to the surgical procedure.

Based on tour of Pharmacy Department, review of Policy and Procedure documentation, interview, and written statement the Pharmacy of the hospital failed to ensure that current and accurate records on the receipt and disposition of Schedule II, III, IV, and V expired narcotics be kept for review.

Findings include:

On 05/12/11 during tour of the Pharmacy, the Pharmacist provided a large plastic bag of expired narcotics for review. The Pharmacist stated that these drugs were the expired narcotics that were pulled from all departments within the hospital. The pharmacist revealed she did not have any documentation to indicate the number of expired narcotics on hand. The Pharmacist revealed she was holding on to these drugs until she got a "batch" to return to the 'Returns Company'. Two (2) surveyors and the Pharmacist counted and recorded the drugs in the plastic bag. The following are the expired narcotics found: Hydrocodone 7.5/500 milligram (mg) - 40 milliliters (ml), Hydrocodone 5mg/334 - 8ml, Nalbuphine Hydrochloride 10mg - 55ml, Fentanyl 50mg - four (4) boxes with five (5) patches per box, Methylphenidate 5mg - 100 tablets, Ritalin 5mg - 120 tablets, Fentanyl 25 microgram (mcg) - three (3) patches, Morphine 5mg injection - two (2) vials, Methadone 10mg - 25 tablets, Morphine Contin 30mg - 25 tablets, Ativan 1mg - 12 tablets, and Loratab 5mg - 10 tablets.

On 05/12/11 at 5:15 p.m. a tour of the Pharmacy Department was performed. While on tour, a large plastic, unlocked box, of Schedule II, III, IV, and V narcotics were discovered sitting on the floor in the Pharmacy Narcotic Room. Various sizes of Ziplock bags with medication bottles and punch-out containers with narcotics inside were noted. The Director of Pharmacy (DOP) revealed that the box of drugs were from another hospital (both hospitals are owned by same company) where she also worked as a part-time pharmacist. The DOP stated, "I try to save money by combining the narcotics into one batch. The 'returns narcotics company' charges me for one visit. My procedure is to wait until I have a quantity large enough to be returned." The DOP was unable to find any documentation where the narcotics were reconciled due to expiration dates. The following is a list of the expired Schedule II, III, IV, and V narcotics found in various size bags: Oxycotin 5/500mg - 27 tablets, Restoril 30mg -7 capsules, Nalbuphine Hydrochloride 10mg vial for injection - three (3), Mepergan Fortis 50/25mg - 51 capsules, Adderall 20mg - 10 tablets, Morphine Sulfate Immediate Release (IR) 30mg - 12 tablets, Adderall 20mg-10 tablets, Morphine Sulfate 20 mg/ml oral solutions - 16 packets, Dilaudid 4mg - 10 tablets, Morphine Sulfate extended release 15 mg - 25 tablets, Duragesic 100mcg/hour - one (1) patch, Mepergan Fortis - 35 capsules, Oxycontin 10mg - three (3) capsules, Oxycontin 10mg - 10 Morphine Contin 30mg - 21 tablets, Morphine Contin 15mg - 70 tablets, Methadone 10mg - 25 tablets, Morphine Sulfate 20mg Oral Solution - 27 packets, Morphine Sulfate 15mg - 60 tablets, Morphine Sulfate 30mg-10 tablets, Dilaudid 2mg - eight (8) vials, Fentanyl 100mg - six (6) patches, Ritalin 5mg - 33 tablets, Fentanyl 100mcg - six (6) patches, Oramorp Sustained Release 30 mg - two (2) tablets, Morphine Sulfate 30 mg Thirty-nine (39) tablets, Lomotil 20mg - 15 tablets, Valium 10mg - 10 tablets, Tylenol with Codeine liquid 5cc - 168 doses in individual sealed cups, Ambien Controlled Release - two, one-half (2.5) tablets, Librium 25mg - 40 tablets, Librium 5mg sixteen (16) tablets, Xanax .25mg - 30 tablets, Lortab Liquid 473 ml, Pentothal 500mg per milliliter (used to put patient asleep) - 16 doses, Darvocet-N-100 - 120 tablets, Propoxphene 100mg - five (5) capsules, Morphine-Contin 15mg - 27 tablets, Darvon 65mg - 83 capsules, Propoxyhene 65mg - 10 capsules, Lortab 5/10 - 10 tablets, Lomotil 3mg - three (3) tablets, and Serax 15mg - 81 tablets.

Review of Policy Number 11-15 revealed the following: "Return of expired Drugs and Devices to the Pharmacy, nursing, and other personnel who discover expired drugs and devices shall return them to the pharmacy for proper disposition."

On 05/12/11 a review of statement provided by Director of Pharmacy (DOP) revealed the following: "Expired drugs from (Hospital #2) which is managed by our facility are brought to (Hospital #1) for pick up by the returns company. I am the pharmacist at both locations. Full time at Hospital #1 and part time at (Hospital #2). Hospital #2 is a three (3) bed acute care hospital. I am on call when needed. Signed, DOP"

Review of a document received from CII Manifest dated 10/20/10 was provided when request for documentation on past return of Scheduled Drugs. Items returned were noted to be "24". Total cost of returns were noted to be $74.02 cents. No other documentation offered.

Based on observation, and testing during the Fire Safety and Consrtuction follow-up/revist of 06/28/11, the hospital failed to be constructed, arranged, and maintained to ensure the safety of patients.

Findings include:

Refer to A709 for the hospital's failure to comply with the Life Safety Code, and A710 for the hospital's failure to comply with the applicable provisions of the Life Safety Code of the National Fire Protection Association.

Based on observation and testing conducted during the revisit survey on 6/28/11, the hospital failed to be constructed, arranged, and maintained to ensure the safety of the patients.

Findings include:

The standard of Life Safety Code is considered not met due to the hospital's failure to comply with the applicable provisions of the Life Safety Code of the National Fire Protection Association. Refer to A710.

Based on observation, and testing during the Fire Safety and Consrtuction follow-up/revist of 06/28/11, the hospital failed to be constructed, arranged, and maintained to ensure the safety of the patients.

Findings include:

Refer to K-025- The hospital failed to provide the one-half (1/2) hour fire resistance rating for smoke barrier walls in an existing fully sprinklered facility.

Refer to K-051 - The facility failed to provide the required audible visual fire alarm notification devices. NFPA 101 Chapter 9.6.3.