HospitalInspections.org

Based on observation, interview, and policy review, the facility failed to follow their policy on Controlled Substances.

Findings include:

On 12/21/10 during morning medication pass, Licensed Nurse #1 administered Ativan 1 milligram to a patient without a second nurse verifying the correct dose and patient prior to administration of the controlled medication.

On 12/21/10 at 10:40 AM, Licensed Nurse #1 indicated that the nurses were to have a second nurse check the dose and patient prior to giving a controlled medication. Licensed Nurse #1 verbalized the procedure was not followed during the morning medication pass.

The adult unit medication room contained the following documentation, dated 3/2/09: "All nurses administering controlled drugs are now required to have one nurse verify the dose and patient is correct prior to administering. Verifying Nurse please sign the designated area, or initial next to the administering nurse ... "

A memo on controlled substances, dated 8/12/10, read, " ... 2 nurse signatures are required when removing a drug from controlled substance inventory. "

Documentation received from the facility, dated 12/21/10, indicated a Registered Nurse did not follow protocol when administering a controlled medication.

Based on observation, interview, and policy review, the facility failed to ensure medications were kept in a secured area.

Findings include:

On 12/21/10 at 11:12 AM, the window to the medication room on the Adult North unit was left open and unattended.

On 12./21/10 at 11:20 AM, Licensed Nurse #19 verbalized it was not appropriate for the medication window to be open, because patients could reach in and take medications, and could "overdose, hide them and give them to peers."

On 12/21/10 at 1:30 PM, Licensed Nurse #1 concurred that patients should not have access to the medication room, as they could take medications, narcotics, sharps, and needles. Licensed Nurse #1 further verbalized the medication room window was to be kept locked when not in use; it was to be opened when giving medication, it was to be shut when not giving medication and not left opened unattended.

The facility's Medication Administration General Guidelines policy, with a revision date of 9/10, documented: "Medications are never left unattended."

Based on document review, interview, and electronic mail communique, the facility failed to ensure specimen examination requirements were determined and defined.

Findings include:

A list of specimens requiring macroscopic examination and those requiring both macroscopic and microscopic examination, as determined by the medical staff and a pathologist, was not present in the laboratory.

This finding was determined by a review of the contract between the facility and the reference laboratory for medical laboratory services, interviews with the medical director of the facility and the hospital sales representative of the contracted reference laboratory on 12/21/10, and an e-mail received on 12/21/10 from the quality assurance manager of the reference laboratory.

Based on observation, interview, and policy review, the facility failed to ensure staff followed its handwashing policy.

Findings include:

On 12/21/10 at 7:48 AM, Licensed Nurse #1 washed her hands using soap and water, rinsed her hands and shut the faucet off with clean wet hands, then obtained a paper towel to dry her hands.

On 12/21/10 at 1:40 PM, Staff Member #18 verbalized the process for washing hands was to use water and soap, lather hands, rinse her hands with water, get a paper towel to shut off the water, then get a paper towel to dry her hands.

On 12/22/10 at 9:35 AM, Licensed Nurse #2 indicated the facility expected staff to know the policy on handwashing and to follow it.

The facility's policy entitled, "Handwashing," dated 6/10, documented: "Dry hands with paper towel while water was still running. Shut off water with dry paper towel and discard. Do not reapply to hands. Faucets are very dirty."