HospitalInspections.org

Based on observations and interviews, the facility failed to ensure that medications were kept at the recommended temperature. Findings include:

During an observation of the emergency department on 9/9/15 beginning at 2:00 p.m., a review of the medication refrigerator logs from July 1, 2015 to September 9, 2015, showed the temperature log was missing six recorded temperatures in July, 16 recorded temperatures missing in August and four recorded temperatures missing from September 1 to September 9, 2015.

During an observation of the emergency department on 9/10/15 at 7:15 a.m., the following medications were stored in the medication refrigerator:

Two RSI kits, one Promethean 25 mg suppository, six 5 mg/ml vials of diltiazem, one vial tetanus IG, 250 units, one vial of Bicillen CR, nine tuberculin tests, eight vials of Famotidine, 20 mg, one vial of Humulin R U 100, one vial Humalog U 100, one vial Tdap, and one vial of LETS.

During an interview on 9/9/15 at 2:45 p.m., staff member R, RN, emergency department, stated the RSI kits and the temperature logs were checked by the night shift, but there have been some travelers lately, so maybe it didn't get done.

During an interview on 9/10/15 at 7:30 a.m., staff member H, RN, emergency department manager, stated there was no written protocol delineating job duties, but the medication refrigerator temperatures should absolutely be checked everyday. It is the standard.

During an observation of the medical surgical unit on 9/10/15 at 8:45 a.m., the medication refrigerator contained the following medications:
1,750mg Vancomycin reconstituted in IV fluid, Oxytocin, two 1 ml vials of Tetracaine, two vials of Hemabate 250 mcg, two vials Methergine, and 14 Fleet glycerin suppositories.

During an interview on 9/10/15 at 8:45 a.m., staff member J, RN, ICU/CCU and medical surgical manager, stated there was no temperature log for the medications in the medical/surgical refrigerator, but the unit coordinator would be responsible for one from now one.

Based on record review and interviews, the facility failed to include admission and/or discharge documentation for patients admitted from acute care to swing bed status for two (#s 11 and 20) of 20 sampled patients.

Patient #11 was admitted to the hospital on 9/1/15 with diagnoses of bipolar disorder, fall and hypoxemia. Patient #11 was transferred to swing bed status on 9/4/15. Review of patient #11's electronic health record reflected a discharge order from acute care was not completed prior to admission to swing bed.

Patient #20 was admitted to the hospital on 2/7/15 for injuries sustained in a motor vehicle accident. Patient #20 was transferred to swing bed status on 2/12/15. Review of patient #20's electronic health record reflected a discharge order from acute care and an admit order to swing bed were not completed prior to the admission to swing bed.

During an interview on 9/9/15 at 8:10 a.m., staff member S, RN, stated there was no discharge order from acute care prior to swing bed admission for patient #11.

During an interview on 9/10/15 at 8:50 a.m., staff member J, RN, Swing Bed Manager, stated there was no discharge order from inpatient status for patients #11 and #20. Staff member J did not know how they "fell through."