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The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See C-231

On 11-3-10 at approximately 1016 in the clean supply room there were 3 boxes of " enemas for children " that were outdated on 7/10.

On 11-3-10 at approximately 1035 in the medication room located on the Medical/Surgical floor there was one open bottle of Betadine that outdated on 2/10.

This finding was confirmed with the Director of Health Information and the Director of Pharmacy on 11-3-10 at approximately 1037.



On 11-3-10 at approximately 1100 the " High " and " Low " control solution bottles for the Blood Monitoring Glucose machine on Med/Surg were dated " 5/10 " .

The product information packet was reviewed with the Technical Supervisor from lab. It was confirmed on 11/05/10 at 1130 that the control bottles expire 90 days from the day of opening.

This finding was confirmed with the Director of Health Information on 11/03/10 at 1100.




29313

Based on observation and interview the facility failed to ensure that all patient-care equipment was maintained in safe operating condition.
Findings include:
During the initial tour of the facility in the Emergency Department on 11/3/10 at approximately 1015 it was found that the following supplies were expired:
1. Trauma Room #1:
a. One pediatric quick pace had expiration date of 5/28/09
b. Two pediatric quick pace had expiration date of 4/28/9
c. One pediatric quick pace combination pack with expiration of 08/28/09
d. Two packages of defibrillator pads with expirations of 3/06 and 4/09
e. One package of disposable EKG sensors expiration of 5/10

2. Triage:
a. Refrigerator log was last dated 9/2010

3. Medication Room:
a. One Polypropylene 6.0 suture with expiration of 9/09
b. Eight Polypropylene 6.0 suture packages with expiration of 3/10

4. Gynecological Exam Room:
a. Four urine specimen collection kits with expiration of 6/30/10

5. Operating Room #1
a. Single use oxygen extension tubing was being reused
b. One Endotracheal Tube size 7.0 was opened and placed back into stock drawer

6. Operating Room #2
a. Single use oxygen extension tubing was being reused
b. Single use suction tubing was on the operating room floor at approximately 1145, with a case scheduled for 1230, with room prepped and ready.
These findings were confirmed by the Assistant Director of Nursing and Certified Registered Nurse Anesthetist.




29314

On 11-3-10 at approximately 1030 in the clean supply room there was a package of surgilube that expired 10-10. This finding was confirmed with the Director of Health Information on 11-3-10 at approximately 1030.

On 11-4-10 at approximately 1300 a policy was requested for expired supplies, the policy provided was titled "Expiration Dates For Multidose Vials & Suspensions" supplies were not included in the policy.

On 11-4-10 at approximately 1415 the Director of Pharmacy stated that no other policy existed that covered supplies.

Based on observation and interview the facility failed to insure that all drugs and biological were appropriately stored. Findings include:
During the initial tour of the facility Pre-operative and Post Anesthesia Care Unit on 11/3/10 at approximately 1110 it was found that medications were kept in the clean utility room unlocked and with unlimited access at all times.
This was confirmed by the Assistant Director of Nursing.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on November 3, 2010, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated November 3, 2010 for Life Safety Code.

Based on observation, policy review and interview the facility failed to ensure that outdated, mislabeled, or otherwise unusable drugs were not available for patient use. Findings include:
During the initial tour of the facility Emergency Department on 11/3/10 at approximately 1000 the following drugs were outdated, mislabeled or otherwise unusable for patient use.
1. Trauma Room #1
a. Three 8 ounce bottles of Actidose with sorbitol that expired 10/10
b. One 8 ounce bottle on Insta-Charcoal that expired 6/10

2. Triage
a. Thirteen 1 cubic centimeter syringes prefilled with no label of medication, date, time or expiration

3. Medication Room
a. Two bottles of meat tenderizer with no open or expiration date
b. One bottle of Accent with no open or expiration date
c. One bottle of baking soda with and expiration date of 8/08
d. One multi-dose of heparin lock flush 100 units/milliliter open 8/26/10 with no expiration date
e. One multi-dose of heparin lock flush 100 units/milliliter open 8/21/10, with no expiration date
f. One bottle of 100 milliliter lidocaine hydrochloride oral, topical solution opened 9/25/10 with no expiration date
g. One multi-dose vial of Lovenox open 9/20/10, with no expiration date
h. One multi-dose vial of Humulin R opened 4/04/10, with no expiration date
i. One 16 ounce bottle of Hydrogen Peroxide with no open date
j. One 16 ounce bottle of alcohol with no open date
k. One 8 ounce bottle of Betadine with no open date

4. Clean Utility Room
a. Eight 4 ounce bottles of Pedialyte with expiration date of 11/1/10
b. One jar of chicken bouillon cubes with an expiration date of 04/10
These findings were confirmed by the Assistant Director of Nursing.


27408




Tour of the Medical/ Surgical floor on 11/03/10 at approximately 1020, revealed that the following medication located in Medication Cart #2 was outdated:

Ativan 1milligram (12 tablets) expired on 8/10
Restoril 30 milligrams (22 tablets) expired on 9/10
Lortab 10/500 milligrams (3tablets) expired on 9/10

This finding was confirmed with the Director of Health Information and the Director of Pharmacy on 11-3-10 at approximately 1025.

Tour of the Medical/ Surgical floor on 11/03/10 at approximately 1030, revealed that the following medication located in Medication Room was outdated:
Rochepin 1 gram (multi dose vial) was open and not dated or timed.

This finding was confirmed with the Director of Health Information and the Director of Pharmacy on 11-3-10 at approximately 1037.

Based on medical record review, interview and policy review the facility failed to ensure that all orders would be signed, dated and timed in 16 of 17 medical records for patient numbers (#4, #11, #12, #13, #14, #15, #17, #18, #20, #21, #22, #24, #25, #26, #37, #41 ). Findings include:

On 11-3-10 at approximately 1045 during review of the medical record for patient #4 the following was revealed:

"D/C (discharge) home today, F/U (follow up) in office in 1 week, D/C meds: Percocet 5/325 1 po (by mouth) Q6H (every 6 hours) prn (as needed)" no date or time was on the order.

"D/C (discontinue) Mag (magnesium) Sulfate IVPB (Intravenous Piggy Back) / May leave IV out. Telephone order not signed, dated or timed.

"Lasix 20mg (milligrams) PO X 1 (by mouth times one) now". Telephone order not signed, dated or timed.

"May D/C IV" voice order not signed, dated or timed.

"Moduritic 5/50mg 1 PO daily". Telephone order not signed, dated or timed.

"BMP ( basic metabolic panel)". Order not timed.

"Cepical throat spray prn, Daily dressing change". Telephone order not dated or timed.

Standing order titled "Pre-Operative Orders" did not include a time.

On 11-4-10 at approximately 1330 a policy was requested for authentication of orders. The policies provided titled "Medical Orders" and "Hills and Dales Rules and Regulations" did not include documentation stating that all orders must be signed, dated and timed, and in what time frame. This was confirmed with the Assistant Director of Nursing on 11-5-10 at approximately 1025.



27408




On 11/04/10 at approximately 1415 during the closed medical record review it was noted:

Patient #37 ' s " Pre-Operative Assessment " did not contain a time when the Nurse Anesthetist completed their " Post Operative Anesthesia Assessment " .


Patient #41 ' s " Pre-Operative Assessment " did not contain a time when the Nurse Anesthetist completed their " Post Operative Anesthesia Assessment " .





29313

Findings include:
During medical record review of patient #11, it was found that the " Physician ' s Order Sheet " had not been signed by the physician.
During medical record review of patient #12, #13, #14 and #15 it was found that the " After Care Instructions to Patient " had not been timed.
During medical record review of patient #16, it was found that the ' Medication Reconciliation and Physician Order " had not been signed, dated or timed by the physician. The " After Care Instructions to Patient " had not been signed, dated or timed by hospital representative who reviewed instructions with the patient.
During medical record review of patient #17 and #18 it was found that the " After Care Instructions to Patient " had not been signed, dated or timed by hospital representative who reviewed instructions with the patient.
During medical record review of patient #20 it was found that the " Special Consent to Operation or Other Procedure " had not been timed by the physician. The " Physician Orders: Post Anesthesia Recovery Orders " had not been dated or timed by the physician. The " Standing Orders-General Pre-Surgical " had not been dated or timed by the physician. The " Physician ' s Order Sheet " had not been dated or timed on two sets of orders. The " History and Physical " had not been dated or timed by the physician. The " Progress Notes " had not been timed or dated by the physician.
During medical record review of patient #21 it was found that the " Special Consent to Operation or Other Procedure " was not timed by the physician. The " Physician ' s Order Sheet " was not dated or timed on one set of orders. The " Standing Orders-General Pre-Surgical " had not been signed, dated or timed by the physician. The " Physician Orders: Post Anesthesia Recovery Orders " had not been dated or timed by the physician. The " Post-Operative Anesthesia Assessment " had not been timed by the Nurse Anesthetist. The " History and Physical " had not been signed, dated or timed by the physician. The " Progress Notes " had not been dated or timed by the physician.
During medical record review of patient #22 it was found that the " Special Consent to Operation or Other Procedure " had not been timed by the physician. The " Standing Orders-General Pre-Surgical " had not been dated or timed by the physician. The " Physician Orders: Post Anesthesia Recovery Orders " had not been dated or timed by the physician. The " Post-Operative Anesthesia Assessment " had not been timed by the nurse anesthetist. The " History and Physical " had not been dated or timed by the physician. The " Progress Notes " had not been dated or timed by the physician.

During medical record review of patient #24 it was found that the " Special Consent to Operation or Other Procedure " had not been timed by the physician. The " Physician ' s Order Sheet " had a verbal order that had not been signed, dated or timed by the physician. The " Operative Report " had not been signed, dated or timed by the physician. The " Medication Reconciliation and Physician Order Form " had not been timed by the physician. The " Progress Notes " had not been dated or timed by the physician. The " Physician ' s Order Sheet " had a verbal order that had not been signed, dated or timed by the physician. The " Physician Orders: Post Anesthesia Recovery Orders " had not been dated or timed by the physician. The " Post-Operative Anesthesia Assessment " had not been timed by the nurse anesthetist. The " History and Physical " had not been dated or timed by the physician.
During medical record review of patient #25 it was found that the " Special Consent to Operation or Other Procedure " had not been timed by the physician. The " History and Physical " had not been dated or timed by the physician. The " Progress Notes " had not been dated or timed by the physician. The " Physician Orders: Post Anesthesia Recovery Orders " had not been dated or timed by the physician. The " Operative Report " had not been signed, dated or timed by the physician. The " Pre-Operative Orders " had not been timed by the physician.
During medical record review of patient #26 it was found that the " Special Consent to Operation or Other Procedure " had not been timed by the physician. The " Discharge Summary " had not been signed, dated or timed by the physician. The " History " had not been dated or timed by the physician. The " Report of Consultation " had not been signed, dated or timed by the physician. The " Physical " had not been dated or timed by the physician. The " Physician Orders: Post Anesthesia Recovery Orders " had not been dated or timed by the physician. The " Admission Progress Note " had not been dated or timed by the physician. The " Progress Notes " had not been dated or timed by the physician. The " Progress Notes " on 10/25/10 had not been signed, dated or timed by the physician. The " Progress Notes " on 10/26/10 had not been signed, dated or timed by the physician. The " Emergency Physician Record " had not been dated or timed by the physician. The " Physician ' s Order Sheet " had verbal orders that had not been signed, dated or timed by the physician.
These findings were confirmed by the Chief Executive Officer and the Assistant Director of Nursing.