HospitalInspections.org

Based on observation and interview with facility staff, it was determined the Hospital failed to post the toll free State Hot Line number available to voice grievances. This had the potential to affect all patients who presented to the Emergency Department (ED) for treatment.


Findings include:


During a tour of the ED on 5/21/13 at 10:45 AM the surveyor noted the toll free State Hot Line phone number for patients to call to voice grievances was not posted in the ED lobby, the triage rooms, the ambulance bay entrance or in the ED treatment rooms. The surveyor observed the posted Patient Rights in the ED lobby did not have the State Hot Line number listed.

During an interview on 5/21/13 at 12:15 PM, Employee Identifier # 7, Emergency Room Director, confirmed the Patient Rights posted in the ED lobby did not contain the State Hot Line number.

Based on observation, review of the facility job description for the Director of Pharmacy and interview with staff, it was determined the facility failed to ensure that all medications stored in pharmacy and provided to the patients were not expired.

This had the potential to affect all patients served by the facility.


Findings include:

Job Description:

Job Title: Director of Pharmacy

Responsible to: Administrator

Duties:
... Thoroughly checks pharmacy inventory periodically...
To assure no stock is used after expiration date recommended by manufacturer...

Drug Return:
... All out dated and otherwise unusable medications will be placed in the pharmacy closet, separated from usable items until they are boxed up and sent to the recycling company for credit or destruction. All outdated control drugs are handled in this manner also.


A tour of the Pharmacy was conducted on 5/22/13 at 9:00 AM. During the tour the following outdated medications were observed and stored with usable medications:

Phenobarbital liquid x (times) 1 bottle expired 7/2012
Promethazine liquid x 1 bottle expired 3/2013
Morphine Sulfate liquid x 1 bottle expired 4/2011
Tylenol with Codeine liquid x 1 bottle expired 7/2010
Lortab elixir ( liquid ) x 1 bottle expired 5/2010

An interview conducted on 5/22/13 at 10:00 AM with EI (Employee Identifier) # 6, Relief Pharmacist, confirmed the aforementioned findings.

Based on observations during a facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.


Findings include:


Refer to Life Safety Code violations.

Based on observation and staff interview, it was determined the facility failed to ensure all medical supplies available for patient use in the facility were not expired and failed to ensure equipment was monitored to maintain safety of patients and staff. This had the potential to affect all patients served by the facility.


Findings include:


1. A tour of the Emergency Department (ED) was conducted on 5/21/13 at 10:45 AM. During the tour the surveyor observed the following expired supplies:

74 packs of Providone-Iodine Swabsticks expired 4/2013
16 Fisherfinest culture swabs expired 12/23/12
4 urine specimen kits expired 1/31/13.

An interview on 5/21/13 at 12:15 PM with Employee Identifier
(EI) # 7, Emergency Room Director, confirmed the aforementioned findings.


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2. During a tour of the physical therapy department on 05/22/13 at 10:55 AM the surveyor observed a hydroculator with packs present. The surveyor requested the temperature monitoring logs and the current temperature of the contents. There were no temperature monitoring logs available for review and there was no thermometer available to monitor the hydroculator temperature.

An interview on 5/22/13 at 11:25 AM with EI # 8, the Physical Therapy Office Manager, confirmed the aforementioned findings.