HospitalInspections.org

Based on tour, observations and interview with key personnel on January 23, 2014, it was determined that the facility failed to assure that patient care equipment was maintained in safe operating condition.

Findings include:

1. During tour of the Emergency Department, in exam room 9, a Pertussis kit contained a reagent with an expiration date of June 9, 2012.

2. This finding was confirmed by the Interim Director of Nursing on January 23, 2014 at approximately 9:30 AM.

3. This finding was previously cited during the November 21, 2013 recertification survey.

Based on review of the sample log at hospital clinics, policy review and interviews with key personnel on January 23, 2014, it was determined that the facility failed to follow their policy related to medications.

Findings include:

1. The facility policy, medication samples-hospital clinics and physician's offices, stated that it's purpose was, "to establish procedures for receipt, storage and distribution of medication samples at WCGH (Waldo County General Hospital) owned physician offices and clinics". It further stated that "drug samples will be logged into the drug sample receipt log...all of this must be double checked for accuracy by a second member of the staff that will also initial the log book. Dispensing of samples is recorded in the medical record and the samples dispensing log."

2. During tour of the WCGH Obstetrics clinic, the surveyor reviewed of the sample log at the clinic which indicated that quantity recorded of Dexilant 60 mg (milligrams), in the log book was twelve (12). The actual count of this medication on the shelve was ten (10). The quantity of Amitiza 24 mcg (micrograms) recorded in the log book was thirty-six (36). The actual count of this medication on the shelve was thirty-two (32).

3. This finding was confirmed by the Physician Services Manager on January 23, 2014 at 11:00 AM.

4. The facility policy, Care of opened solutions, general considerations, directed staff to "discard when expired per information on container".

5. During tour of the medical/surgical unit, the medication room contained an IV (intervenous) tray with an open vial of Lidocaine 1%, with an expiration date of January 20, 2014.

6. This finding was confirmed by the Medical Surgical Nurse Manager on January 23, 2014 at 12:25 p.m.

7. This finding was previously cited during the November 21, 2013 recertification survey.

Based on record review, by-law review and interviews with key staff on January 23, 2014, it was determined that the facility failed to assure that physician's orders were countersigned within 72 hours, in one (1) of fourteen (14) medical records. (Record F)

Findings include:

1. The Medical Staff By-Laws, Rules and Regulations stated, "Physician verbal/telephone orders must be countersigned, dated and timed by the practitioner within seventy-two (72) hours."

2. The medical record of Patient F contained three (3) V.O's. (verbal orders) dated January 18, 2014. As of January 23, 2014, these V.O's. had not been countersigned.

3. This finding was confirmed by the Medical Surgical Nurse Manager on January 23, 2014, at approximately 12:30 p.m.

4. This finding was previously cited during the November 21, 2013 recertification survey.