HospitalInspections.org

Based on observation (1of 3), interview with facility staff (1 of 1) and review of policies (1 of 1) the hospital failed to ensure the proper disposition of medications.

Findings include:

During a tour of the hospital's radiology department's 3 procedure rooms on 01/23/2012 at 1300 with Radiology Manager B outdated contrast media was discovered. 5 100 ml. bottles of Isovue 370 (a contrast media) with expiration dates of 10/2011 were stored in a cabinet of the CT room (153). Manager B confirmed the presence of the expired media and admitted it should have been removed.

Hospital policy PH020-2700 entitled: "Identification, removal and disposal of outdated/unusable drugs" states; "It is a joint responsibility of all personnel handling and administering medications to constantly monitor medications for quality and freshness. The pharmacy department must check any medication that is suspect." It further states: "All outdated, unusable, contaminated or suspected medications are to be returned to the pharmacy department."

Based on observation (1 of 1), interview with facility staff (1 of 1) and policy (1 of 1) the hospital failed to ensure the removal of outdated food.

findings include:

During a tour of the kitchen with Food Service Director C on 01/23/2012 at 1530 outdated supplies were found in the storage room. 24 8 ounce cans of Promote with fiber (a high protein nutritional drink) with expiration dates of 01/01/12 were discovered on the shelf. Director C stated at the time that the cans should have been removed.

According to the food service policy on expired products: "All expired products will be discarded by use by or expiration date."

Based on 6 of 30 medical records reviewed (#1,2,3,4,5 &6 ), staff interview and policy review the hospital failed to ensure all documentation was timed and dated.

Findings include:

Patient #1 was seen in the emergency department (ED) on 12/16/2011 and required a transfer to another facility. The physician failed to include a date and time when signing the transfer form.

Patient #2 was seen in the ED on 12/23/2011 and required a transfer to another facility. The physician failed to include a date and time when signing the transfer form.

Patient #3 was seen in the ED on 12/24/2011 and required a transfer to another facility. The physician failed to include a date and time when signing the transfer form.

Patient #4 was seen in the ED on 12/20/2011 and required a transfer to another facility. The physician failed to include a date and time when signing the transfer form.

Patient #5's medical record contained a swing bed program communication form with a lower portion containing physician orders. These orders were not timed or dated by the physician.

Patient #6's medical record contained a swing bed program communication form with a lower portion containing physician orders. These orders were not timed or dated by the physician.

The above findings were confirmed during the course of record review (01/25 and 01/26/2012) by RN F.

Hospital policy HIM 500-002 entitled: "Identification/authorship and authentication of medical staff and allied health professional signatures" states the following: "All entries must be legible, timely, and meaningful and complete and must be authenticated and dated and/or timed by the person (identified by name and title) who is responsible for ordering, providing, or evaluating the service furnished."

Based on staff interviews (2 of 2), patient interviews (1 of 2), review of swing bed medical records (8 of 8 ), and hospital policy the facility failed to provide organized activities or a director of activities..

Findings include:

Per interview with Swing Bed Admissions Social Worker E on 01/24/2012 at 1415 an activities program is being developed. E stated that the hospital did not have an activities director at present and that they were in the process of organizing activities and a calendar.

Per interview with occupational therapist D on 01/26/2012 at 1150 the activities program for swing bed patients is still being developed. She stated that activity calendars have yet to be posted in patients' rooms.

Per interview with swing bed patient #7 on 01/24/2012 at 1545 she does not recall being offered any activities apart from those directly related to her care. There was no calendar of activities posted in patient #7's room.

Per review of medical records of swing bed patients the only activities offered were independent activities including, "books/magazines, TV/movies, and puzzles/word finds", visits from friends and family was also listed as an activity.

Hospital policy entitled, "Swing unit activities program" delineates the procedure for providing patients activities during a swing bed admission. These include; "The swing bed activity program be overseen by designated personnel"," Based on (an) assessment the patient will be offered individual and group activities which will promote and/or enhance their quality of life." "All swing bed patients will have the monthly calendar of activities that are offered at hours of convenience for the patients' participation on a daily basis, to include evenings and weekends."