HospitalInspections.org

Based on observation and interview, the provider failed to ensure medical supplies in the operative suite and in the emergency department (ED) were not outdated and available for patient use. Findings include:

1. Observation on 8/7/12 from 1:00 p.m. until 2:55 p.m. of the operating suite revealed:
*The anesthesia machine in the operating room (OR) had a canister of Sodasorb (soda lime carbon dioxide absorbent) installed on the machine. That canister of Sodasorb had an expiration date of April 2011.
*The certified registered nurse anesthetist's (CRNA) storage closet contained:
-One box of approximately twenty-five, one-inch, Monoject safety needles with an expiration date of November 2007.
-One Ambu laryngeal mask with an expiration date of June 2008.
-One LMA laryngeal mask with an expiration date of March 2012.

Interview with surgical technologist B at that time confirmed the above findings. She further revealed:
*The last time the anesthesia gas machine had been used in the OR was during a tonsillectomy and adenoidectomy on July 3, 2012.
*The CRNAs had the responsibility of ensuring all of their anesthesia supplies were not outdated and available for patient use.

The provider had no policy and procedure related to outdated supplies.



23059

2. Observation on 8/7/12 at 1:30 p.m. in the auxiliary emergency room (ER) revealed two of ten 3/8 inch, 16 millimeter sutures had expired in December 2010.

Interview with registered nurse C at that time revealed supplies in the ER were to have been checked monthly for outdates. She stated she was unsure why those sutures remained available for use.

Based on observation, interview, and policy review, the provider failed to ensure:
*Accountability of a schedule III medication in one of one pharmacy.
*Medications were removed from use when outdated in one of one medication room.
Findings include:

1. Observation on 8/7/12 at 9:00 a.m. revealed a stock bottle of hydrocodone/acetaminophen (APAP) 5/500 milligrams (mg) in the pharmacy. Count of the tablets remaining in that bottle by the pharmacist revealed there were fifty-eight tablets. Review of the documentation sheet accounting for that medication revealed there should have been sixty-four tablets in that bottle.

Interview with the pharmacist at that time revealed when the pharmacist was not available the charge nurse would have been responsible for removing and signing medications out of the pharmacy. She stated an ongoing log was maintained for all scheduled medications removed from the pharmacy. She stated an actual count of schedule III and IV medications in the pharmacy occurred every three months. She stated when an inaccuracy was found she would do a search to see if she could find where an error might have occurred. She confirmed if those medications had been missing she would not have been aware of it until an actual count was completed every three months.

Interview on 8/7/12 at 10:30 a.m. with the pharmacist revealed she had found the error in documentation. Removal of the above medication had been documented on the wrong form.

Review of the provider's April 2012 pharmacy policy revealed:
*The pharmacy department was responsible for the storage, control, and dispensing of all medications.
*The pharmacist or designated substitute was responsible for making periodic inspections of all drug storage or medication centers.

Review of the provider's August 2011 policy on controlled substance administration and accountability procedures revealed:
*Every two months a physical inventory of all controlled substances was to have been taken and double-checked against the perpetual logs.
*In order to ensure accountability of class III, IV, and V medications each dose was to have been signed out on the appropriate form.
*The pharmacist was to have reviewed medications signed out on a daily basis.

2. Observation on 8/7/12 at 9:00 a.m. in the nursing unit medication room revealed some stock controlled medications were packaged in sixteen-unit cassettes. Review of those cassettes revealed:
*Two hydrocodone/APAP 5/500 mg tablets outdated December 2010.
*Twelve Demerol 50 mg tablets outdated March 2011.
*Thirty-two oxycodone/APAP 5/500 mg tablets outdated March 2012.
*Twenty-two morphine sulfate extended release (MS-ER) 30 mg tablets outdated April 2012.
*Sixteen MS-ER 15 mg tablets outdated May 2012.
*Eight hydrocodone/APAP 5/500 mg tablets outdated July 2012.

Interview at that time with the pharmacist revealed a registered nurse (RN)/pharmacy technician was responsible for ensuring medications maintained in the medication room had not outdated. She stated those medications were routinely checked for outdates monthly. She confirmed it was her expectation those medications should have been removed from the medication room and not available for patient use.

Review of the provider's August 2011 policy on outdated and/or unusable medication systems review revealed:
*A log was maintained of the dates each drug stored in the hospital would outdate.
*That log was to have been checked monthly, so that any medications that would be expiring would have been removed from stock prior to expiration.
*Any outdated medication was to have been removed from access and placed in a box in the pharmacy.

Based on observation, interview, policy review, and professional standards, the provider failed to ensure one of one registered nurse (RN) A had not documented medication administration prior to the administration of medications to one of one patient (39) during a medication pass. Findings include:

1. Observation on 8/8/12 at 9:30 a.m. of RN A revealed she had prepared and administered the following oral (PO) and intravenous (IV) medications to patient 39:
*Zithromax, ten milliliters (ml) of 200 milligram (mg) per five ml liquid, PO.
*Zyrtec, one chewable 10 mg tablet, PO.
*SoluMedrol, 60 mg per 0.96 ml, IV.
*Potassium chloride, 10 millequivalents per 7.5 ml liquid, PO.

Interview with RN A after the above medications had been given to patient 39 revealed RN A had already documented in the patient's electronic medication administration record (EMAR) that the above medications had been given prior to administering them to patient 39. She further revealed:
*That was the system the provider had used for documenting medication administration in the electronic medical record (EMR).
*If for any reason the medications had not been given or had been refused she could go back into the EMAR and change the documentation of the medication administration.

Interview on that same day at 11:00 a.m. with the chief nursing officer confirmed the nurses had been documenting the administration of medications prior to actually giving them to the patients. She further stated:
*If the nurses had waited to document the medications after the fact they might have gotten "pulled away," and then the documentation would not have been done.
*The nurses could have gone into the EMR "after the fact" and documented if a medication had been dropped or refused and/or not given to the patient for any other reason.
*The medication administration policy and procedure in the provider's nursing service policy and procedure manual was in place prior to the implementation of the EMR.
*The provider's policy and procedure for medication administration had changed since the facility had implemented their EMR in February 2012.

Review of the provider's nursing service policy and procedure reviewed in May 2012 revealed:
*Nurses were to set-up the medications, administer them, and chart them on the MAR.
*Medications should have been charted as soon as they had been given.

Review of the provider's new Use of the Medication Administration Record policy and procedure reviewed in October 2011 revealed:
*Medications should have been "administered and documented by a registered nurse and by other certified/licensed/registered personnel" and "in adherence with South Dakota Codified Laws, Statutes, Professions and Occupations," hospital policy, and defined scopes of practice appropriate to the discipline.
*Documentation would occur after the medication had been administered or as soon as possible thereafter.
*The actual time of the administration would also have been documented on the MAR.

Review of the South Dakota Board of Nursing statement dated 10/17/06 revealed "It is the position of the South Dakota Board of Nursing that the standard for safe administration of medication includes the practice of documenting medication following administration to the patient."

Based on observation and interview, the provider failed to ensure medical supplies in the operative suite and in the emergency department (ED) were not outdated and available for patient use. Findings include:

1. Observation on 8/7/12 from 1:00 p.m. until 2:55 p.m. of the operating suite revealed:
*The anesthesia machine in the operating room (OR) had a canister of Sodasorb (soda lime carbon dioxide absorbent) installed on the machine. That canister of Sodasorb had an expiration date of April 2011.
*The certified registered nurse anesthetist's (CRNA) storage closet contained:
-One box of approximately twenty-five, one-inch, Monoject safety needles with an expiration date of November 2007.
-One Ambu laryngeal mask with an expiration date of June 2008.
-One LMA laryngeal mask with an expiration date of March 2012.

Interview with surgical technologist B at that time confirmed the above findings. She further revealed:
*The last time the anesthesia gas machine had been used in the OR was during a tonsillectomy and adenoidectomy on July 3, 2012.
*The CRNAs had the responsibility of ensuring all of their anesthesia supplies were not outdated and available for patient use.

The provider had no policy and procedure related to outdated supplies.



23059

2. Observation on 8/7/12 at 1:30 p.m. in the auxiliary emergency room (ER) revealed two of ten 3/8 inch, 16 millimeter sutures had expired in December 2010.

Interview with registered nurse C at that time revealed supplies in the ER were to have been checked monthly for outdates. She stated she was unsure why those sutures remained available for use.

Based on observation, interview, and policy review, the provider failed to ensure:
*Accountability of a schedule III medication in one of one pharmacy.
*Medications were removed from use when outdated in one of one medication room.
Findings include:

1. Observation on 8/7/12 at 9:00 a.m. revealed a stock bottle of hydrocodone/acetaminophen (APAP) 5/500 milligrams (mg) in the pharmacy. Count of the tablets remaining in that bottle by the pharmacist revealed there were fifty-eight tablets. Review of the documentation sheet accounting for that medication revealed there should have been sixty-four tablets in that bottle.

Interview with the pharmacist at that time revealed when the pharmacist was not available the charge nurse would have been responsible for removing and signing medications out of the pharmacy. She stated an ongoing log was maintained for all scheduled medications removed from the pharmacy. She stated an actual count of schedule III and IV medications in the pharmacy occurred every three months. She stated when an inaccuracy was found she would do a search to see if she could find where an error might have occurred. She confirmed if those medications had been missing she would not have been aware of it until an actual count was completed every three months.

Interview on 8/7/12 at 10:30 a.m. with the pharmacist revealed she had found the error in documentation. Removal of the above medication had been documented on the wrong form.

Review of the provider's April 2012 pharmacy policy revealed:
*The pharmacy department was responsible for the storage, control, and dispensing of all medications.
*The pharmacist or designated substitute was responsible for making periodic inspections of all drug storage or medication centers.

Review of the provider's August 2011 policy on controlled substance administration and accountability procedures revealed:
*Every two months a physical inventory of all controlled substances was to have been taken and double-checked against the perpetual logs.
*In order to ensure accountability of class III, IV, and V medications each dose was to have been signed out on the appropriate form.
*The pharmacist was to have reviewed medications signed out on a daily basis.

2. Observation on 8/7/12 at 9:00 a.m. in the nursing unit medication room revealed some stock controlled medications were packaged in sixteen-unit cassettes. Review of those cassettes revealed:
*Two hydrocodone/APAP 5/500 mg tablets outdated December 2010.
*Twelve Demerol 50 mg tablets outdated March 2011.
*Thirty-two oxycodone/APAP 5/500 mg tablets outdated March 2012.
*Twenty-two morphine sulfate extended release (MS-ER) 30 mg tablets outdated April 2012.
*Sixteen MS-ER 15 mg tablets outdated May 2012.
*Eight hydrocodone/APAP 5/500 mg tablets outdated July 2012.

Interview at that time with the pharmacist revealed a registered nurse (RN)/pharmacy technician was responsible for ensuring medications maintained in the medication room had not outdated. She stated those medications were routinely checked for outdates monthly. She confirmed it was her expectation those medications should have been removed from the medication room and not available for patient use.

Review of the provider's August 2011 policy on outdated and/or unusable medication systems review revealed:
*A log was maintained of the dates each drug stored in the hospital would outdate.
*That log was to have been checked monthly, so that any medications that would be expiring would have been removed from stock prior to expiration.
*Any outdated medication was to have been removed from access and placed in a box in the pharmacy.

Based on observation, interview, policy review, and professional standards, the provider failed to ensure one of one registered nurse (RN) A had not documented medication administration prior to the administration of medications to one of one patient (39) during a medication pass. Findings include:

1. Observation on 8/8/12 at 9:30 a.m. of RN A revealed she had prepared and administered the following oral (PO) and intravenous (IV) medications to patient 39:
*Zithromax, ten milliliters (ml) of 200 milligram (mg) per five ml liquid, PO.
*Zyrtec, one chewable 10 mg tablet, PO.
*SoluMedrol, 60 mg per 0.96 ml, IV.
*Potassium chloride, 10 millequivalents per 7.5 ml liquid, PO.

Interview with RN A after the above medications had been given to patient 39 revealed RN A had already documented in the patient's electronic medication administration record (EMAR) that the above medications had been given prior to administering them to patient 39. She further revealed:
*That was the system the provider had used for documenting medication administration in the electronic medical record (EMR).
*If for any reason the medications had not been given or had been refused she could go back into the EMAR and change the documentation of the medication administration.

Interview on that same day at 11:00 a.m. with the chief nursing officer confirmed the nurses had been documenting the administration of medications prior to actually giving them to the patients. She further stated:
*If the nurses had waited to document the medications after the fact they might have gotten "pulled away," and then the documentation would not have been done.
*The nurses could have gone into the EMR "after the fact" and documented if a medication had been dropped or refused and/or not given to the patient for any other reason.
*The medication administration policy and procedure in the provider's nursing service policy and procedure manual was in place prior to the implementation of the EMR.
*The provider's policy and procedure for medication administration had changed since the facility had implemented their EMR in February 2012.

Review of the provider's nursing service policy and procedure reviewed in May 2012 revealed:
*Nurses were to set-up the medications, administer them, and chart them on the MAR.
*Medications should have been charted as soon as they had been given.

Review of the provider's new Use of the Medication Administration Record policy and procedure reviewed in October 2011 revealed:
*Medications should have been "administered and documented by a registered nurse and by other certified/licensed/registered personnel" and "in adherence with South Dakota Codified Laws, Statutes, Professions and Occupations," hospital policy, and defined scopes of practice appropriate to the discipline.
*Documentation would occur after the medication had been administered or as soon as possible thereafter.
*The actual time of the administration would also have been documented on the MAR.

Review of the South Dakota Board of Nursing statement dated 10/17/06 revealed "It is the position of the South Dakota Board of Nursing that the standard for safe administration of medication includes the practice of documenting medication following administration to the patient."