HospitalInspections.org

Based on review of facility documents and staff interview(EMP), it was determined that the facility failed to follow established policies and procedures that track the movement of scheduled drugs through of the hospital.

Findings include:

Review of facility policy, C-II Controlled Drug System, revised March 16, 2016, revealed "... Polices and procedures are provided with the intent to handle these drugs appropriately and to deter drug abuse, mishandling, diversion, or loss. ... Administration Documentation ... d. For any controlled medication not stocked in the ADC, the nurse should document the following on the Narcotic Perpetual Inventory Sheet: ... Nurse signature/co-signature when drug or portion of drug wasted. ... Wasting Of Narcotics 1. All C-II drugs wastage, whether partial or full doses, must be handled appropriately. a. All wasted C-II doses, whether partial or complete doses, must be destroyed by two nurses together, or one nurse and one pharmacy staff member (or two pharmacy personnel if done in the pharmacy department). Both people must verify the waste amount and either document the waste in Omnicell, or sign his/her names on green narcotic sheet. ... c. If not done in Omnicell, the inventory sheet must be completed in full for a wasted dose, including two nurse signatures. Also needed on the inventory sheet is the reason for wastage, when wasting full dosages."

Review of a sample of seventeen ACMH Hospital Controlled Drug Records, for medication area, Interventional Radiology and Angio, dated between December 9, 2016, to February 6, 2017, revealed no area for the documentation for the reason of wasting full dosages, as described in the facility's policy.

Telephone interview conducted on February 15, 2017, at 3:15 PM with EMP11 confirmed the controlled drug record does not contain an area to document the reason for wastage when wasting full doses.

During a tour of Interventional Radiology Suite on February 10, 2017, at approximately 11:00 AM, the medication cart was unlocked by EMP10. Two syringes labeled Fentanyl and Versed were observed.

EMP10 was questioned about the syringes and stated that [they were] waiting for another nurse to come and witness the waste of the medications. It was also revealed the nurse to witness the medication waste did not observe EMP10 drawing up the medication.

An interview conducted February 14, 2017, at 09:30 AM, with EMP6 revealed "There is only one nurse when we draw up narcotics. The nurse that witnesses the waste is not present when the medications are drawn up to be administered. The witness comes down after the case is over."

An interview conducted February 14, 2017, at approximately 9:30 AM with EMP7 confirmed the above findings.

Based on facility policy, documentation, and staff interview (EMP), it was determined that the facility failed to ensure that personal shielding (lead aprons) are routinely inspected by the hospital.

Findings include:

Review of facility policy entitled, Testing Procedures, dated September 2008, revealed "Test: Frequency Procedure ... Apron Checks 6 months Radiation Physicist ... ."

A tour was conducted on February 10, 2017, at approximately 1:15 PM of Surgical Services department. Observation revealed 21 lead aprons and 10 thyroid shields hanging on a rack located in an operating room hallway. Of the 21 lead aprons, 9 failed to have numeric identification number and 6 of 8 Thyroid shields failed to have a numeric identification number.

EMP9 revealed, they did not know who is responsible for the checks and inventory of lead aprons.

A telephone interview conducted February 15, 2017, at 11:00 AM with EMP2 revealed "I do not have a specific list for the OR, not accurate list. ... The OR aprons are scattered throughout. ... If there is a new apron in x-ray, I know about it, if OR or another department, I may not. Procedure needs to be changed."

Based on review of facility documents, observation, and staff interviews (EMP), it was determined the facility failed to follow adopted cleaning/sanitizing policies in the Nutrition Services Department, and failed to adopt a policy that included the provision for the cleaning/sanitizing of all equipment in the Nutrition Services Department.

Findings include:

Review of the facility's policy entitled "Cleaning/Sanitizing", dated August 2016, revealed "Purpose: It is the policy of the Nutrition Services Department to clean and sanitize all equipment and work surfaces to minimize the possibility of contamination. Objectives: 1. All equipment, work surfaces (food contact surfaces), and work areas are cleaned and sanitized as follows: A. Cafeteria Tables ... B. Steam Tables ... C. Hot Beverage Dispenser ... D. Microwave Oven ... E. Refrigerators ... F. Ice Machines ... G. Dishmachine ... ."

During a tour of the Nutrition Services Department on February 10, 2017, at 10:00 AM with EMP12, EMP13, and EMP14, dust was noted on the top and back of the oven ; dust was noted on the top of the steamer, and back of steamer, in the vent area, and dust was also noted on top of the pizza oven. In addition, two open grate shelf racks were noted in the area of the ovens, in which lower racks were noted to store spices, pasta bags, and onions. There was dust noted on the top shelf of each rack.

Findings were confirmed by EMP12, EMP13, and EMP14, on February 10, 2017, and it was also stated that no routine monitoring is completed related to the cleanliness of above mentioned equipment.

During review of the facility's policy entitled "Cleaning/Sanitizing", dated August 2016, it was noted that the policy did not include provisions for all equipment, such as the ovens and open grate shelf racks.

Based on Life Safety Code Validation survey completed on January 31, 2017, the Condition for Physical Environment is not met. See the Life Safety Code 2567 for the deficiencies.