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Based on observation, interview, and review of the facility's policy, it was determined the facility failed to follow the policy related to written notification as responses to grievances filed for ten (10) patients of ten (10), who filed grievances, failed to have written responses sent by the facility. Patients #11, 12, 13, 14, 15, 16,17, 18, 19 and 20.

The findings include:

Review of the facility's policy regarding Grievance Procedures, revised on 04/16/13, revealed if the patient was discharged prior to resolution of the concern, the Patient Advocate would send a written response to the patient within ten (10) working days from the date the concern was reported. Any written grievance and supporting documentation would be sent to the manager of the department involved in the concern for the patient advocate. After the written grievance was reviewed by the parties as outlined above, a written response would be communicated to the patient.

1. Review of the grievance log revealed Patient #11's mother filed a grievance on 02/22/12. The grievance was resolved on 02/29/12; however, there was no evidence a written notice had been sent.

2. Review of the grievance log revealed Patient #12's spouse filed a grievance on 03/19/12 and the grievance log revealed a resolved date of 3/20/12; however, there was no evidence a written response had been sent.

3. Review of the grievance log revealed Patient #13's mother filed a grievance, on 03/26/12, there was no evidence a written response had been sent, and there was no resolved date on the grievance log.

4. Review of the grievance log revealed Patient #14's family filed a grievance on 05/07/12 and there was no evidence a written response had been sent, and there was no resolved date on the grievance log.

5. Review of the grievance log revealed Patient # 15's wife filed a grievance on 05/23/12. The grievance log revealed a resolved date of 05/25/12; however there was no evidence a written response had been sent to the wife.

6. Review of the grievance log revealed Patient #16 filed a grievance on 06/20/12. The grievance log revealed no resolved date, and no evidence a written response had been sent to the patient.

7. Review of the grievance log revealed Patient #17's daughter filed a grievance on 10/25/12, there was no resolved date, and no evidence a written response had been sent.

8. Review of the grievance log revealed Patient #18 filed a grievance on 11/11/12, there was no resolved date, and no evidence a written letter had been sent to the patient.

9. Review of the grievance log revealed Patient #19 filed a grievance on 10/03/12, there was no resolved date, and no evidence a written response had been sent to the patient.

10. Review of the grievance log revealed Patient #20's grandfather filed a grievance on 05/18/12. The log revealed no resolved date, and no evidence a written response had been sent.

Interview with the Risk Manager, on 04/17/13 at 11:30 am, revealed she was responsible for handling the grievances, and stated the hospital tried to resolve all issues while the patient was in the hospital, if possible, and revealed most were resolved per telephone. The Risk Manager stated they didn't usually send out letters unless the hospital received a written letter from the complainant. The Risk Manager stated she had been placing everything on the grievance log, some of which were not actually grievances. The Risk Manager also revealed the hospital policy stated they should be sending written responses within ten (10) days, and she had not understood that she should be doing this. The Risk Manager could not give a reason why there were no resolved dates on seven (7) of the ten (10) grievances reviewed.

Interview with the Chief Nursing Officer, on 04/17/13 at 1:45 PM, revealed the grievance log was maintained and handled by the Risk Manager. The CNO stated the grievance policy required a written response within ten (10) days; however, revealed the hospital had not been following this. The CNO stated if they could resolve the grievance by calling the person filing the grievance, they would consider the grievance resolved.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to implement their policy to ensure safe administration of drugs for patients. The facility failed to ensure multi dose vials and multi dose packs were dated when opened and/or removed from use when expired.

The findings include:

Review of the facility's policy titled Expiration Dates, Drug Allergies, Drug Interactions, Crushing Meds, Stat Meds, and Unclear or Questionable Orders, revised on 06/22/12, revealed multi-dose vials were to be dated and initialed after opening, (any vial with no date would be thrown away). All multi dose vials would be discarded after twenty-eight (28) days from the original date opened.

Review of the facility's policy regarding Medication Security and Storage revealed any medication found expired, improperly stored or unsecured in the listed areas would be removed from the area and disposed of by the Pharmacy technician.

1. Observation during a medication pass for Patient #2, on 04/16/13 at 9:35 AM, Central Time, revealed Registered Nurse (RN) #1 drew 0.3 ml of Lovenox from a multi dose vial and injected the medication into the patient's right abdomen. Further observation of the Lovenox multi dose vial revealed no date when opened.

Interview with RN #1, on 04/16/13 at 9:40 AM, revealed she had not checked the multi dose vial for a date opened and did not know when the vial had been opened.

2. Inspection of the Emergency room, Trauma #1, on 04/16/13 at 10:15 AM, revealed a multi dose vial of Lidocaine with an open date of 02/22/13 inside an unlocked cabinet. Further observation revealed an expiration date of 01/01/13.

Interview with RN #2, who was present at the time of the above observation, revealed she was unaware the multi dose vial of Lidocaine was in the Trauma #1's cabinet. She stated the facility rarely used multi dose vials and she was not the nurse who had opened the vial on 02/22/13 and used the medication.

3. During inspection of the Doc U Med System at the nurse's station, on 04/16/13 at 1:30 PM, revealed one (1) box of Valium 5mg (22 tabs in the box) with no expiration date listed on the box.

Interview with Registered Nurse (RN) #1, on 04/16/13 at 1:30 PM, revealed medications were checked by pharmacy daily for any expired dates, and the date should be listed on each medication, which is then brought to the nurse's station. In addition, RN #1 stated that nurses are responsible for labeling and dating all medications when opened and the Valium should have had an expired date on the box.

Interview with the Pharmacist, on 04/16/13 at 8:25 AM, revealed the pharmacy always tried to put the expiration dates on all the products sent to the floor, and stated this would be a standard of practice.

4. Inspection of the anesthesia cart, on 04/17/13 at 9:30 AM, revealed two (2) bottles of Bumonidine 2% eye drops, which had been opened. One (1)bottle did not have a date when opened labeled on the bottle, and the second bottle had a date opened, of 10/01/12, which was expired according to the facility's policy.

Interview with the Chief Nursing Officer (CNO), on 04/17/13 at 9:40 AM, revealed she had spoken to the night shift nurse who had opened the expired multi dose vial of Lidocaine on 02/22/13 and the nurse said she had failed to look for an expiration date when opening the Lidocaine. The nurse was unavailable to be interviewed at this time. The CNO stated all multi dose vials were to be dated when opened and nurses were supposed to look for expiration dates prior to using the drug.

Continued interview with the CNO revealed pharmacy completes rounds of the emergency room and checks for expired medications daily. However, further interview revealed pharmacy checked all crash carts, anesthesia carts, and medication carts. They do not look in the cabinets. Pharmacy conducted audits and brought that information to the Quality Assurance meetings.

Interview with the pharmacist, on 04/17/13 at approximately 11:00 AM, revealed she was only responsible for checking the crash carts. She did not know where the expired Lidocaine multi dose vial came from.

Interview with the Pharmacy Director, via telephone, on 04/17/13 at 10:15 AM, revealed the anesthesia carts were checked monthly by a pharmacy technician, and any expired medications were discarded. The Director stated there was a log kept in the pharmacy that had all areas checked when inspected monthly. The log was not produced by the facility during the survey.






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