HospitalInspections.org

Based on medication storage recommendation, observation, and interview it was determined the facility staff failed to ensure that anesthesia medications were labeled with an appropriate expiration date after being removed from the refrigerator as recommended by the manufacturer.

Findings:

1. The manufacturer's recommendation for the storage are as follows: Store in refrigerator at 2? to 8?C (36? to 46?F). The multi-dose vials are only stable for up to 14 days at room temperature without significant loss of potency.

2. During a June 22, 2011 afternoon tour of the operating room (OR) suite, accompanied by the OR Nurse Manager, the OR Nurse Educator and the Director of Outpatient Surgical Services, four vials of Succinylcholine (a paralyzing agent) were noted unrefrigerated, in the medication draw of an anesthesia cart. The drug vials failed to contain a date or any evidence as to when the vials were removed from refrigeration.

3. In a June 22, 2011 afternoon interview with the anesthesia technician who stocks the anesthesia carts, she reported that she used to date the Succinylcholine vials when they came out of the refrigerator to be destroyed after 14 days but, she no longer does that.

Based on observation and interview it was determined that the hospital's pharmacy director failed to ensure that all compounding of drugs was performed in the pharmacy.

Findings:

1. During a June 22, 2011 afternoon tour of the pre-op holding area, accompanied by the O.R. nurse manager, the O.R. nurse education and the Director of Outpatient Surgery Services, one opened multi-dose vial of 1% Xylocaine and one opened single dose vial of Sodium Bicarbonate were noted in a medication cabinet. The Sodium Bicarbonate single-dose vial was labeled with the date opened. The multi-dose vial of 1% Xylocaine was labeled with the date and time opened. The surveyor asked the OR nurse manager if the Sodium Bicarbonate had been mixed into the 1% Xylocaine vial to buffer it and she replied, "Yes." She said the pre-op nurse mixes the Sodium Bicarbonate into the Xylocaine each morning for the day's use. When questioned why the Sodium Bicarbonate vial was labeled with the date, she reported they kept the Sodium Bicarb vial so that the other nurses would know it had been mixed in the Xylocaine. When questioned why the pharmacy was not doing this compounding of drugs, the nurse manager replied, "I have had the conversation with the Chief Pharmacist about mixing these drugs. I have tried to address this."

2. In a June 23, 2011 afternoon interview with the Chief Pharmacist, she reported that she was aware that the nurses were compounding these drugs for the surgical services. She acknowledged that she was aware that nurses were not allowed to perform this task. She stated that as of 6 a.m. on June 23, 2011, the pharmacy has assumed the task of compounding these medications for surgical services.

Based on observation and policy and procedure review, it was determined that the hospital staff failed to ensure proper infection control practices were followed in the endoscopy suite.

Findings:

1. The facility policy #IC600-007 titled, "Infection Prevention and Control," last reviewed May 16, 2011 reads in part, "D. Personal Protective Equipment , 4. Gowns b. Soiled or contaminated gowns shall be removed as soon as possible or upon exiting the patient room. c. Disposable gowns shall not be reused for repeated contacts with the same patient. "

2. During a June 22, 2011 morning tour of the endoscopy suite accompanied by the Director of Endoscopy Suite and Outpatient Services, a medical staff member was observed at 10:15 a.m. walking down a public hallway wearing a blue disposable gown over his street clothes. The gown was noted to be tied at the waist and untied at the neck. During the above mentioned tour of the endoscopy suite, the same physician was observed in the PACU (Post Anesthesia Care Unit) at 10:25 a.m. talking with a PACU patient with the same blue disposable gown on, tied in the same manner. At 10:35 a.m., the same physician was observed in an endoscopy procedure room with a different patient wearing the same blue disposable gown, untied at the neck and tied around the waste.

3. During the above mentioned tour of the endoscopy suite, observation of the storage closet for scopes used in the endoscopy unit revealed the scopes were hanging in a manner allowing curvature at the bottom and touching the floor of the closet. This resulted in the scopes' failure to dry properly and potential contamination by touching the floor.