HospitalInspections.org

Based on a review of documentation and interviews it was determined the facility failed to assure the safety of patient in non-medical emergencies as evidence by not simulating evacuation of patients during fire drills.

Findings were:

During a review of fire drill documentation for the time period of 8-2010 through 7-2011, 12 of 12 documents reviewed gave no indication that the evacuation of patients was simulated during the drills. An interview with Jennie Whipff (Maintenance Director) on 8-10-11 confirmed that evacuation of patients was not simulated during the drills.


The above was confirmed in an interview with the Administrator and the Chief Nursing Officer in the facility conference room on the afternoon of 8-10-11.

Based on observation, review of records, and interviews it was determined the facility governing body failed to monitor and assure policies were implemented to provide quality health care as evidence by physician assistant orders without required physician countersignature and the presence of expired medication in multiple areas of the facility.

Findings were:

Facility Medical Staff Rules & Regulations page 8, Section 5 titled Medical Record Entries Requiring Countersignature states, " Orders made by Residents and Physician Assistants are required to be co-signed by a " Licensed Practitioner " who is a M.D., D.O. or DDS/DMD covered either by an institutional license or an individual license to practice medicine in the State of Texas. "

During a review of the clinical records for 13 inpatients, 12 of the 13 records (patients #2, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20 & #21) contained orders written by a physician assistant that had not been cosigned by the M.D.

Facility policy titled Policy - Multiple Dose/Single Dose Vials/Containers states, in part, " ...When multiple dose medication vials/containers are used, they shall be discarded after 90 days or by the expiration date designated by the manufacturer (which ever comes first) or when they become contaminated. "

During a tour of the patient care unit on 8-10-11, 1 of 1 multi-dose vial of Novolog insulin was marked as having been opened on 10-19-10, but was still available for patient use.

During a tour of the patient care unit on 8-10-11, 3 of 3 pre-filled vials of influenza vaccine had expired on 6-30-11 but were still available for patient use.

During a tour of the patient care unit on 8-10-11, 1 of 1 multi-dose vial of Humalog insulin was marked as having been opened 11-3-10, but was still available for patient use.

During a tour of the emergency department on 8-10-11 (room #1), 2 of 3 multi-dose vials of Atarax had expired 8-1-11 but were still available for patient use.

During a tour of the emergency department on 8-10-11 (room #1), 4 of 4 multi-dose vials of Furosemide had expired (1 on 6-11, 3 on 8-1-11) but were still available for patient use.

During a tour of the emergency department on 8-10-11 (room #1), 1 of 1 vial of Solu-Cortef had expired 6-11 but was still available for patient use.

During a tour of the emergency department on 8-10-11 (room #1), 2 of 2 multi-dose vials of Amiodarone had expired 5-11 but were still available for patient use.

During a tour of the emergency department on 8-10-11 (room #1), 2 of 2 multi-dose vials of Metoprolol had expired on 6-11 but were still available for patient use.

During a tour of the emergency department on 8-10-11 (room #1), 4 of 7 carpujects of Epinephrine had expired 6-11 but were still available for patient use.

During a tour of the emergency department on 8-10-11 (room #1), 4 of 5 intravenous, 1000ml bags of dextrose 5% had expired on 7-11 but were still available for patient use.

During a tour of the emergency department on 8-10-11 (room #1), 3 of 3 tiger-top laboratory tubes had expired (2 on 6-09, 1 on 5-11) but were still available for patient use.

The above was confirmed in an interview with the Administrator and the Chief Nursing Officer in the facility conference room on the afternoon of 8-10-11.

Based on review of records and interviews it was determined the doctor of medicine failed to participate in the facility written policy as evidence by not countersigning physician assistant orders per policy.

Findings were:

Facility Medical Staff Rules & Regulations page 8, Section 5 titled Medical Record Entries Requiring Countersignature states, " Orders made by Residents and Physician Assistants are required to be co-signed by a " Licensed Practitioner " who is a M.D., D.O. or DDS/DMD covered either by an institutional license or an individual license to practice medicine in the State of Texas. "

During a review of the clinical records for 13 inpatients, 12 of the 13 records (patients #2, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20 & #21) contained orders written by a physician assistant that had not been cosigned by the M.D.

The above was confirmed in an interview with the Administrator and the Chief Nursing Officer in the facility conference room on the afternoon of 8-10-11.

Based on observation and interviews it was determined the facility failed to assure that outdated drugs were not available for patient use.

Findings were:

Facility policy titled Policy - Multiple Dose/Single Dose Vials/Containers states, in part, " ...When multiple dose medication vials/containers are used, they shall be discarded after 90 days or by the expiration date designated by the manufacturer (which ever comes first) or when they become contaminated. "

During a tour of the patient care unit on 8-10-11, 1 of 1 multi-dose vial of Novolog insulin was marked as having been opened on 10-19-10, but was still available for patient use.

During a tour of the patient care unit on 8-10-11, 3 of 3 pre-filled vials of influenza vaccine had expired on 6-30-11 but were still available for patient use.

During a tour of the patient care unit on 8-10-11, 1 of 1 multi-dose vial of Humalog insulin was marked as having been opened 11-3-10, but was still available for patient use.

During a tour of the emergency department on 8-10-11 (room #1), 2 of 3 multi-dose vials of Atarax had expired 8-1-11 but were still available for patient use.

During a tour of the emergency department on 8-10-11 (room #1), 4 of 4 multi-dose vials of Furosemide had expired (1 on 6-11, 3 on 8-1-11) but were still available for patient use.

During a tour of the emergency department on 8-10-11 (room #1), 1 of 1 vial of Solu-Cortef had expired 6-11 but was still available for patient use.

During a tour of the emergency department on 8-10-11 (room #1), 2 of 2 multi-dose vials of Amiodarone had expired 5-11 but were still available for patient use.

During a tour of the emergency department on 8-10-11 (room #1), 2 of 2 multi-dose vials of Metoprolol had expired on 6-11 but were still available for patient use.

During a tour of the emergency department on 8-10-11 (room #1), 4 of 7 carpujects of Epinephrine had expired 6-11 but were still available for patient use.

During a tour of the emergency department on 8-10-11 (room #1), 4 of 5 intravenous, 1000ml bags of dextrose 5% had expired on 7-11 but were still available for patient use.

During a tour of the emergency department on 8-10-11 (room #1), 3 of 3 tiger-top laboratory tubes had expired (2 on 6-09, 1 on 5-11) but were still available for patient use.

The above was confirmed in an interview with the Administrator and the Chief Nursing Officer in the facility conference room on the afternoon of 8-10-11.