HospitalInspections.org

Cross refer to:

C0224

Based on interviews and a tour of the facility, the facility did not have preventive maintenance programs in place to ensure that drugs were appropriately stored. Failure to properly store drugs can result in safety issues for patients and staff.

Findings were:

Facility Pharmacy Department policy #4 titled "Pharmacy Program" states, in part:
"Policy
B. Controlled Area should:
1. Be a designated area which is clean, well lighted, away from outside traffic, and of sufficient size to perform daily functions.
C. Security Requirements:
2. The pharmacist should be responsible for the security of the pharmacy, including adequate safeguards against theft or diversion of dangerous drugs, controlled substances, and records for such drugs.
3. The pharmacy should have locked storage for Schedule II, III, IV, and V controlled substances and other drugs requiring additional security."

In interviews with staff #7 and #8 on 7-27-15, both staff members stated that the patient care area contained no "medication room" and that the medications ordered for patients were obtained directly from the pharmacy by the nurse administering the medication. Both staff members stated that the patient care nurses had keys to the pharmacy and could enter the pharmacy at any time. When asked by the surveyor if entrance to the pharmacy (during or after pharmacy hours) required two nurses, they stated that it did not.

On 7-29-15, staff #9 was observed entering the pharmacy, obtaining medication and leaving the pharmacy. In an interview with staff #9 conducted upon exiting the pharmacy, staff #9 was asked why he/she had need to enter the pharmacy. Staff #9 stated that he/she entered the pharmacy to obtain acetaminophen for a patient's fever, which had been ordered on an as-needed basis.

Facility Job Description for "Pharmacy Technician" states, in part:
JOB SUMMARY:
Under supervision of a Pharmacist, fills physicians orders, assists with monitoring drug therapy, the stocking and dispensing of pharmaceuticals and the control of narcotics and controlled substances.

ESSENTIAL DUTIES AND RESPONSIBILITIES:
C.1. Maintains narcotics and controlled substances rcords as required by law and policy.
2. Assists in stock control and issues supplies to other departments."

A brief tour of the pharmacy was conducted on 7-27-15. Within the pharmacy was an automated dispensing system and wall shelves filled with boxes containing topical creams and ointments, rectal medications, injectables, inhaled medications, eye drops and ear drops. During an interview with staff #15 in the facility pharmacy on 7-27-15, staff #15 was asked how inventory (of the medications in boxes) was tracked. Staff #15 stated that he/she conducted an ongoing, manual inventory of the medications in the shelved boxes. When asked how a discrepancy would be handled, staff #15 stated that he/she had never discovered a discrepancy during the manual inventory. When asked by the surveyor to provide documentation of the manual inventory, staff #15 was unable to do so.

During a tour of the pharmacy on 7-29-15, a box containing home medications belonging to patient #22 (who was currently an inpatient) was found sitting on a countertop near the sink, unsecured. Within the box of home medications was a properly labeled bottle containing a quantity of 17 hydrocodone/acetaminophen 5/500 tablets, a Schedule II narcotic medication.

Reference site www.dea.gov defines Schedule II narcotics as "drugs with a high potential for abuse...with use potentially leading to severe psychological or physical dependence."

In an interview with staff #15, staff #15 was asked when patient #22 had been admitted to the facility. Staff #15 stated that patient #22 had been admitted to the facility on the evening of 7-27-15, almost 48 hours prior to the tour of the facility. When asked why the patient's home medications had not been inventoried and the Schedule II medication secured, staff #15 stated that the inventory of any home medication was the responsibility of the patient's nurse, but that he/she (staff #15) had no record of any inventory. As no documentation of inventory of the home meds could be produced, the facility had no way to ensure that patient #22 would leave the facility with all of his/her home meds.

In interviews with staff #8 and staff #15, both staff members concurred that the facility did not have a policy addressing patient home meds brought to the hospital upon admission of the patient.

The above was confirmed in an interview with the Chief Executive Officer on the evening of 7-29-15 in the facility conference room.

Cross refer to:

C0241

Based on a review of documentation, interviews with staff and a tour of the facility, the facility failed to have a governing body responsible for implementing and monitoring policies that ensure that the facility provides quality health care in a safe environment. Failure to implement and monitor these policies can result in an increased risk of harm and infection to patients and staff.

Findings were:

Facility Food Service policy #2 titled "SANITATION/CLEANING" states, in part:
"Procedure:
B.7.a. Wash temperature should be 160 degrees Fahrenheit."

A review of the food service document titled "DAILY LOG OF FOOD TEMPERATURES REFRIGERATORS, FREEZERS, AND DISH MACHINE" revealed that, for the month of July 2015, the dishwasher had never reached a wash temperature higher than 134 degrees Fahrenheit.

Facility Pharmacy Department policy #4 titled "Pharmacy Program" states, in part:
"Policy
B. Controlled Area should:
1. Be a designated area which is clean, well lighted, away from outside traffic, and of sufficient size to perform daily functions.
C. Security Requirements:
2. The pharmacist should be responsible for the security of the pharmacy, including adequate safeguards against theft or diversion of dangerous drugs, controlled substances, and records for such drugs.
3. The pharmacy should have locked storage for Schedule II, III, IV, and V controlled substances and other drugs requiring additional security."

In interviews with staff #7 and #8 on 7-27-15, both staff members stated that the patient care area contained no "medication room" and that the medications ordered for patients were obtained directly from the pharmacy by the nurse administering the medication. Both staff members stated that the patient care nurses had keys to the pharmacy and could enter the pharmacy at any time. When asked by the surveyor if entrance to the pharmacy (during or after pharmacy hours) required two nurses, they stated that it did not.

On 7-29-15, staff #9 was observed entering the pharmacy, obtaining medication and leaving the pharmacy. In an interview with staff #9 conducted upon exiting the pharmacy, staff #9 was asked why he/she had need to enter the pharmacy. Staff #9 stated that he/she entered the pharmacy to obtain acetaminophen for a patient's fever, which had been ordered on an as-needed basis.

Facility Job Description for "Pharmacy Technician" states, in part:
JOB SUMMARY:
Under supervision of a Pharmacist, fills physicians orders, assists with monitoring drug therapy, the stocking and dispensing of pharmaceuticals and the control of narcotics and controlled substances.

ESSENTIAL DUTIES AND RESPONSIBILITIES:
C.1. Maintains narcotics and controlled substances rcords as required by law and policy.
2. Assists in stock control and issues supplies to other departments."

A brief tour of the pharmacy was conducted on 7-27-15. Within the pharmacy was an automated dispensing system and wall shelves filled with boxes containing topical creams and ointments, rectal medications, injectables, inhaled medications, eye drops and ear drops. During an interview with staff #15 in the facility pharmacy on 7-27-15, staff #15 was asked how inventory (of the medications in boxes) was tracked. Staff #15 stated that he/she conducted an ongoing, manual inventory of the medications in the shelved boxes. When asked how a discrepancy would be handled, staff #15 stated that he/she had never discovered a discrepancy during the manual inventory. When asked by the surveyor to provide documentation of the manual inventory, staff #15 was unable to do so.

During a tour of the pharmacy on 7-29-15, a box containing home medications belonging to patient #22 (who was currently an inpatient) was found sitting on a countertop near the sink, unsecured. Within the box of home medications was a properly labeled bottle containing a quantity of 17 hydrocodone/acetaminophen 5/500 tablets, a Schedule II narcotic medication.

Reference site www.dea.gov defines as Schedule II narcotic as "drugs with a high potential for abuse...with use potentially leading to severe psychological or physical dependence."

In an interview with staff #15, staff #15 was asked when patient #22 had been admitted to the facility. Staff #15 stated that patient #22 had been admitted to the facility on the evening of 7-27-15, almost 48 hours prior to the tour of the facility. When asked why the patient's home medications had not been inventoried and the Schedule II medication secured, staff #15 stated that the inventory of any home medication was the responsibility of the patient's nurse, but that he/she (staff #15) had no record of any inventory. As no documentation of inventory of the home meds could be produced, the facility had no way to ensure that patient #22 would leave the facility with all of his/her home meds.

The above was confirmed in an interview with the Chief Executive Officer on the evening of 7-29-15 in the facility conference room.

Cross refer to:

C0276

Based on a review of documentation, interviews with staff and a tour of the facility, patient care policies were not followed regarding the storage, handling, dispensation, and administration of drugs and biologicals. The drug storage area was not administered in accordance with accepted professional principles and accurate records were not kept of the receipt and disposition of all scheduled drug. Failure to follow these policies can result in an increased risk for patient harm.

Findings were:

Facility Pharmacy Department policy #4 titled "Pharmacy Program" states, in part:
"Policy
B. Controlled Area should:
1. Be a designated area which is clean, well lighted, away from outside traffic, and of sufficient size to perform daily functions.
C. Security Requirements:
2. The pharmacist should be responsible for the security of the pharmacy, including adequate safeguards against theft or diversion of dangerous drugs, controlled substances, and records for such drugs.
3. The pharmacy should have locked storage for Schedule II, III, IV, and V controlled substances and other drugs requiring additional security."

In interviews with staff #7 and #8 on 7-27-15, both staff members stated that the patient care area contained no "medication room" and that the medications ordered for patients were obtained directly from the pharmacy by the nurse administering the medication. Both staff members stated that the patient care nurses had keys to the pharmacy and could enter the pharmacy at any time. When asked by the surveyor if entrance to the pharmacy (during or after pharmacy hours) required two nurses, they stated that it did not.

On 7-29-15, staff #9 was observed entering the pharmacy, obtaining medication and leaving the pharmacy. In an interview with staff #9 conducted upon exiting the pharmacy, staff #9 was asked why he/she had need to enter the pharmacy. Staff #9 stated that he/she entered the pharmacy to obtain acetaminophen for a patient's fever, which had been ordered on an as-needed basis.

Facility Job Description for "Pharmacy Technician" states, in part:
JOB SUMMARY:
Under supervision of a Pharmacist, fills physicians orders, assists with monitoring drug therapy, the stocking and dispensing of pharmaceuticals and the control of narcotics and controlled substances.

ESSENTIAL DUTIES AND RESPONSIBILITIES:
C.1. Maintains narcotics and controlled substances rcords as required by law and policy.
2. Assists in stock control and issues supplies to other departments."

A brief tour of the pharmacy was conducted on 7-27-15. Within the pharmacy was an automated dispensing system and wall shelves filled with boxes containing topical creams and ointments, rectal medications, injectables, inhaled medications, eye drops and ear drops. During an interview with staff #15 in the facility pharmacy on 7-27-15, staff #15 was asked how inventory (of the medications in boxes) was tracked. Staff #15 stated that he/she conducted an ongoing, manual inventory of the medications in the shelved boxes. When asked how a discrepancy would be handled, staff #15 stated that he/she had never discovered a discrepancy during the manual inventory. When asked by the surveyor to provide documentation of the manual inventory, staff #15 was unable to do so.

During a tour of the pharmacy on 7-29-15, a box containing home medications belonging to patient #22 (who was currently an inpatient) was found sitting on a countertop near the sink, unsecured. Within the box of home medications was a properly labeled bottle containing a quantity of 17 hydrocodone/acetaminophen 5/500 tablets, a Schedule II narcotic medication.

Reference site www.dea.gov defines as Schedule II narcotic as "drugs with a high potential for abuse...with use potentially leading to severe psychological or physical dependence."

In an interview with staff #15, staff #15 was asked when patient #22 had been admitted to the facility. Staff #15 stated that patient #22 had been admitted to the facility on the evening of 7-27-15, almost 48 hours prior to the tour of the facility. When asked why the patient's home medications had not been inventoried and the Schedule II medication secured, staff #15 stated that the inventory of any home medication was the responsibility of the patient's nurse, but that he/she (staff #15) had no record of any inventory. As no documentation of inventory of the home meds could be produced, the facility had no way to ensure that patient #22 would leave the facility with all of his/her home meds.

In interviews with staff #8 and staff #15, both staff members concurred that the facility did not have a policy addressing patient home meds brought to the hospital upon admission of the patient.

The above was confirmed in an interview with the Chief Executive Officer on the evening of 7-29-15 in the facility conference room.