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CARSON TAHOE REGIONAL MEDICAL CENTER
Standard-level Tag for Pharmaceutical Service
Tag No.: A0490
Based on observation, interview, and record review, the hospital failed to store a medication within the temperature range recommended by the manufacturer.
Findings include:
On 1/10/18 at 10:45 AM, a tour of the Cancer Center pharmacy (a pharmacy affiliated with main hospital) was conducted with the Pharmacist. The pharmacy consisted of an anteroom and a sterile compounding (medication mixing) area, entered from the anteroom through glass doors. The compounding area had medications stored in bins affixed to the wall. A thermometer located on the wall of the anteroom indicated 81 degrees Fahrenheit (F). At 10:52 AM, the thermometer indicated 82 F.
On 1/10/18 at 10:53 AM, the Pharmacist reported the pharmacy air temperature should not be higher than 72 F. The Pharmacist revealed they communicated a request to reduce the pharmacy temperature to a hospital maintenance staff person, but the issue was not resolved. The Pharmacist described the temperature in the compounding area as the same as the anteroom. The Pharmacist confirmed medications were stored in the compounding area. The Pharmacist described each medication should be stored within temperature ranges recommended by the manufacturer to keep the medication stable.
On 1/10/18 at 10:55 AM, a medication stored in the compounding area was Cyclophosphate for Injection, 1 gram vial (used to treat cancer). The manufacturer's label indicated to store the vial at or below 77 degrees F.
Review of the Cancer Center Pharmacy Temperature Log Report indicated the pharmacy air temperature was measured daily, and averaged 76 F from 12/1/17 through 1/9/18. On 1/10/18 at 7:15 AM, the temperature was documented as 81 degrees F.
On 1/10/18 at 3:15 PM, the Pharmacy Manager reported they were not aware of a concern regarding air temperature at the Cancer Center Pharmacy. The Pharmacy Manager revealed the target air temperature range for medication storage areas was approximately 58 to 77 degrees F. The Pharmacy Manager stated medications should be stored within the temperature ranges recommended by the manufacturer.
The hospital policy and procedure titled "Pharmacy-Sterile Prep Storage," dated 9/21/16, indicated the temperature of drug storage areas must be monitored and recorded daily. If the temperature was outside of range, adjust and recheck in one hour. If the temperature was still outside of range, notify the pharmacist in charge, and the maintenance department, and take appropriate steps to protect the integrity of the medications.
MAINTENANCE OF PHYSICAL PLANT
Tag No.: A0701
Based on observation and interview, the facility failed to repair a hole in the wall of the dirty utility room on the Behavioral Health Services (BHS) C unit, which was an off site satellite location.
Findings include:
On 1/10/18 at approximately 11:50 AM, during a tour of the facility, the dirty utility room on the BHS C unit was observed to have a hole in the wall above the hopper sink. The hole was approximately five inches by five inches and pink insulation was exposed and plumbing hardware was visible. The plastic covering behind the plumbing hardware was broken, exposing the hole in the wall.
During interview on 1/10/18 at approximately 11:50 AM, the administrator acknowledged the finding.