HospitalInspections.org

Based on document review and interviews the facility staff failed to ensure the physicians orders were followed as written for 2 of 15 patients, Patient #1 and #14.

The findings include:

On 10/16 and 17/2012 the medical record of Patient #1 was reviewed and revealed the following information. Patient #1 was a 9 year old admitted on 4/14/11 and discharged on 12/13/11. Patient #1 was diagnosed with Spinal Bifida s/p multiple VP shunt revisions, seizure disorder, organic affective disorder and loss of hearing and vision on the right side.

The Nursing Assessment initiated on 4/14/11 at 1800 noted Patient #1 had weakness of both lower extremities and used lofstrand crutches and AFO (Ankle Foot Orthotic) bilaterally.

The physician admission orders on 4/14/11 noted the skin of Patient #1 was to be checked daily. The nursing care plan for Patient #1 initiated on 4/20/11 did not include skin assessments or assessment of the proper placement of Patient #1's AFO. Nursing Care Plans(NCP) were reviewed and revised on 5/6/11, 5/20/11, 6/1/11, 6/14/11,7/1/11, 7/15/11, 7/28/11, 8/11/11, 9/8/11, 9/22/11, 10/6/11, 10/20/11 and 11/1/11 and they did not include as goals or objectives skin assessments or assessment of the proper placement of Patient #1's AFO. The evaluation of nursing interventions on NCP noted the following:
6/1/11 "Routine wound care provided as ordered."
6/14/11 "Daily skin checks performed"
7/1/11 "Duoderm is applied to (L) great toe to encourage healing of abrasion"
7/15/11 "Duoderm still applied to (L) great toe et healing noted"
7/28/11 "Replacement of duoderm to (R) great toe Q 3 days continues"
8/11/11 "Duoderm being used on (R) great toed with little improvement noted"
9/8/11 "Replicare in place of duoderm in applied to (R) greater toe"
9/22/11 "Left great toe was re-examined by the Dr. and new orders were received to wash with soap and water twice a day and to cover with replicare. PT (Physical Therapy) to examine her toe in relationship to the fit of there AFOs (new) and padding and adjustments were made."
10/6/11 "Replicare applied BID on (R)
A review of Patient Care Flow Sheets from 4/15/11 to 11/29/11 revealed skin assessment were not documented as being done by a check mark, were documented as IND, had a line drawn through the box or had no documentation at all for 3 of 3 shifts. On 6/3/11, 9/21/11 and 9/23/11 no skin assessments were indicated as being done.
Also on the Patient Care Flow Sheets there is a place to document splint schedule and or cast care/circ. checks.
The Director of Nursing (DON) was asked to explain the how to interpreted the check marks, IND and the line drawn through the box. She stated, "The check mark indicates a skin assessment was performed, IND indicates the child independently did her own skin assessment and the line means it was not done because it wasn't needed."
The DON stated the Registered Nurse (RN) completed a Random Monthly Routine Nursing Assessment. The Random Monthly Routine Nursing Assessment were reviewed for 9/17/11 through 11/29/11 the form indicated there was skin breakdown but did not indicate where. One of the forms indicated treatment was being provided but did not identify where or the type of treatment.

Patient #14 was a 14 year old wheel chair bound who was admitted on 3/7/12 with the diagnoses of cerebral palsy and organic affective disorder. The medical record was reviewed on 10/18/12 and revealed the following: 3/7/12 physician order to wear AFO and reposition q2h (every 2 hours) at night.

The Patient Care Flow Sheet does not contain any documentation of Patient #14 being turned and repositioned q2h as ordered by the physician. There is documentation of Patient #14 turning and repositioning self. There is no documentation of Patient #14's AFO being assessed for correct placement or of a weekly or monthly skin assessment by the RN.

The Employee #12 stated, "(Name of Patient #14) could actually turn self. We should have documented daily skin checks and proper placement of the AFO. It should not be documented self or independent."

Based on document review and interviews the facility staff failed to ensure the Nursing Care Plans were reviewed and revised for 2 of 15 patients, Patient #1 and #14.

The findings include:

On 10/16 and 17/2012 the medical record of Patient #1 was reviewed and revealed the following information. Patient #1 was a 9 year old admitted on 4/14/11 and discharged on 12/13/11. Patient #1 was diagnosed with Spinal Bifida s/p multiple VP shunt revisions, seizure disorder, organic affective disorder and loss of hearing and vision on the right side.

The Nursing Assessment initiated on 4/14/11 at 1800 noted Patient #1 had weakness of both lower extremities and used lofstrand crutches and AFO (Ankle Foot Orthotic) bilaterally.

The physician admission orders on 4/14/11 noted the skin of Patient #1 was to be checked daily. The nursing care plan for Patient #1 initiated on 4/20/11 did not include skin assessments or assessment of the proper placement of Patient #1's AFO. Nursing Care Plans(NCP) were reviewed and revised on 5/6/11, 5/20/11, 6/1/11, 6/14/11,7/1/11, 7/15/11, 7/28/11, 8/11/11, 9/8/11, 9/22/11, 10/6/11, 10/20/11 and 11/1/11 and they did not include as goals or objectives skin assessments or assessment of the proper placement of Patient #1's AFO. The evaluation of nursing interventions on NCP noted the following:
6/1/11 "Routine wound care provided as ordered."
6/14/11 "Daily skin checks performed"
7/1/11 "Duoderm is applied to (L) great toe to encourage healing of abrasion"
7/15/11 "Duoderm still applied to (L) great toe et healing noted"
7/28/11 "Replacement of duoderm to (R) great toe Q 3 days continues"
8/11/11 "Duoderm being used on (R) great toed with little improvement noted"
9/8/11 "Replicare in place of duoderm in applied to (R) greater toe"
9/22/11 "Left great toe was re-examined by the Dr. and new orders were received to wash with soap and water twice a day and to cover with replicare. PT (Physical Therapy) to examine her toe in relationship to the fit of there AFOs (new) and padding and adjustments were made."
10/6/11 "Replicare applied BID on (R)
A review of Patient Care Flow Sheets from 4/15/11 to 11/29/11 revealed skin assessment were not documented as being done by a check mark, were documented as IND, had a line drawn through the box or had no documentation at all for 3 of 3 shifts. On 6/3/11, 9/21/11 and 9/23/11 no skin assessments were indicated as being done.
Also on the Patient Care Flow Sheets there is a place to document splint schedule and or cast care/circ. checks.
The Director of Nursing (DON) was asked to explain the how to interpreted the check marks, IND and the line drawn through the box. She stated, "The check mark indicates a skin assessment was performed, IND indicates the child independently did her own skin assessment and the line means it was not done because it wasn't needed."
The DON stated the Registered Nurse (RN) completed a Random Monthly Routine Nursing Assessment. The Random Monthly Routine Nursing Assessment were reviewed for 9/17/11 through 11/29/11 the form indicated there was skin breakdown but did not indicate where. One of the forms indicated treatment was being provided but did not identify where or the type of treatment.
Patient #1's Nursing Care Plans did not have any documentation related to skin assessments or the use of AFOs

Patient #14 was a 14 year old wheel chair bound who was admitted on 3/7/12 with the diagnoses of cerebral palsy and organic affective disorder. The medical record was reviewed on 10/18/12 and revealed the following: 3/7/12 physician order to wear AFO and reposition q2h (every 2 hours) at night.

The Patient Care Flow Sheet does not contain any documentation of Patient #14 being turned and repositioned q2h as ordered by the physician. There is documentation of Patient #14 turning and repositioning self. There is no documentation of Patient #14's AFOs being assessed for correct placement or of a weekly or monthly skin assessment by the RN.

There was no documentation on the Nursing Care Plan related to Patient #14's need to be repositioned or the evaluation of Patient #14's skin related to the use of AFOs.

The Employee #12 stated, "(Name of Patient #14) could actually turn self. We should have documented on the care plan daily skin checks and proper placement of the AFOs."

Based on observations, staff interviews, review of pharmacy audits, looking at three crash carts and Quality minutes, the hospital failed to ensure the Pharmacy department was storing or dispensing medications in a safe and appropriate manner to patients.

The findings include:

An inspection of the emergency drug kit revealed the security seal was intact. The seal was broken to inspect the emergency drug kit. There were two vials of Sodium Bicarbonate and one 10 ml vial of furosomide that was found broken inside the kit. There was broken glass spread around the individual compartments holding the medications.

The MFI asked the pharmacist to inspect the emergency drug box. He hesitated and stated, "It's pretty stuffy in there." MFI asked him to look at the emergency drug box to explain the broken glass. He stated, "It had been dropped. The units crash carts are inspected monthly."

The medication room of unit 2 was then inspected. The inspection revealed narcotic counts were not being done every shift. The DON stated, "The narcotic counts are to be completed every shift." In October, at the time of inspection there were forty two times the narcotic counts should have been completed; five checks were missing. The DON stated, "They are to be done at the change of each shift per our policy." For the month of September there were ninety narcotic checks to be done and four were missed.

The pharmacist stated the last time the Virginia Board of Pharmacy inspected the hospital pharmacy was done April 5, 2012. A copy of this inspection was later provided.

The individual patient medication drawers were also inspected. One patient's medication drawer contained Somatropin 12 mg which had expired October 11, 2012 and an unlabeled insulin pen.

An inspection of the refrigerator on unit 2 revealed a box of Lantus insulin labeled for a Patient #13. Inside that same box was one Novolog pen and two Lantus pens. There were no labels on any of the insulin pens. The pharmacist stated, "She (Patient #6 ) was never on Novolog. I don't know why that's in there". The DON stated, "She (Patient #6) is now on an insulin pump."

On Unit 2 the cabinet that stored medications for emergency after hours use was inspected and revealed the following expired medications:
Two tubes of Pemethrin cream 60g (grams) (2.2 oz) expired September 9, 2012.
One sodium chloride 10 ml (milliliter) vial was stored opened, unknown if accessed
Five Vancomycin 500 mg expired September 1, 2012.
Six Chlorzoxazone 500 mg tabs expired April 2012
Ten tabs of Carbomazepine 100 mg had expired June 2012
One Simethicone 80 mg expired April 2012.

An inspection of Unit six A revealed a Chekstix Combo Pak that is used for urinalysis checks expired August 2012. An inspection of the crash cart emergency drug box on Unit 6 (shared by 6 A and B) revealed the following:
Three vials of Epinephrine 1 mg expired October 1, 2012.
Two 4 ml vials of Levophed expired October 1, 2012
Two vials of 10 ml Furosimide expired October 1, 2012.
Two vials of Dopamine 5 ml that expired August 2012.
The DON and Director of Plant Operations both said they were "dismayed" when commenting on the number of expired medications.

An inspection of Unit seven's crash cart revealed the following:
2 - 2 ml ampoules of Digoxin had expired May 2012
Two vials of Vasopressin 1 ml expired May 2012
One vial of Sodium Chloride 0.9% 10 mls expired July 2012.
Two amps of Solu Medrol 2 ml expired May 2012
Two Furosimide 10 ml vials expired October 1, 2012
One vial of Dopamine 5 ml expired August 2012.
Three vials of Epinephrine 1 ml expired October 1, 2012.
Ventolin inhaler that expired September 2012.

The DON provided narcotic counts for the remaining units. She explained that some of the units may not have had patients on narcotics for certain periods and so the narcotic counts on these units may vary. On unit 6 A, narcotic counts were looked at for the month of August, September, and through October 15, 2012. There were 231 narcotic counts to be done every shift. A total of 7 were not done. On unit 6 B narcotic counts were looked at from September to October 15, 2012. Out of a possible 138 counts, 3 were missed. On unit 7 A narcotic counts were looked at for month of September through October 15, 2012. Out of a possible 138 counts, 19 were missed. Unit 8 narcotic counts for the months of August, September, through October 15, 2012 had a possible 231 narcotic counts during this timeframe, and 36 were not done. The pharmacist stated during the tour, " Each unit received a pharmacy audit every month " .

The DON provided a copy of the pharmacy contract. The contract revealed on page one Article One section (i) it states "Pharmacy Inventory Management". It goes on to say the Pharmacy company "shall manage the Customer's Pharmacy inventory in accordance with industry standards". These "inventory management responsibilities include "Drug procurement, monthly inspections for out of date drugs". It also states "management of breakage".

During the tour the facility pharmacist (Employee #6) was called to the unit. The pharmacist stated, "The last Board of Pharmacy inspection for the hospital pharmacy was April 5, 2012." A copy of the inspection report was requested and revealed the pharmacy was cited deficiencies for repackaging drugs that were "labeled with an expiration date exceeding the expiration date of the stock bottle".

The pharmacist provided copies of the pharmacy audits done on the units from May through September 17, 2012. These audits revealed that each unit was being inspected monthly for expired medications and documented there were none found on any of the units. These audits were discussed with the DON. The DON was unable to clearly point out were the narcotic counts were being monitored.

The Pharmacy & Therapeutics (P&T) committee minutes were reviewed. The policy states the P&T is to meet every quarter. The last documented meeting was March 27, 2012.
A review of the Medical Staff/Medical Executive/Credentialing Committee revealed some pharmacy communication at the June 26, 2012 meeting but no mention of monitoring narcotic counts on the units or the management of outdated drugs. The Quality minutes were reviewed and the Director of Quality was asked how the pharmacy ties in to the Quality meetings. The Director of Quality was unable to demonstrate or provide data to substantiate that this pharmacy piece is being done consistently or at all.

Based on observation, staff interviews and review of committee minutes the hospital failed to ensure that the pharmacy was actively involved in committees responsible for establishing and monitoring medication related policies.

The findings include:

The Pharmacy & Therapeutics (P&T) committee minutes were reviewed. The policy states the P&T is to meet every quarter. The last documented meeting was March 27, 2012.

A review of the Medical Staff/Medical Executive/Credentialing Committee revealed some pharmacy communication at the June 26, 2012 but no mention of monitoring narcotic counts on the units or the management of outdated drugs. The Quality minutes were reviewed and the Director of Quality was asked how the pharmacy ties in to the Quality meetings. The Director of Quality was unable to demonstrate or provide data to substantiate that this pharmacy piece is being done consistently or at all.

Based on review of documents and interviews the hospital pharmacy failed to demonstrate a consistent and organized procedure for keeping accurate records of narcotics.

The findings include:

On 10/15/12 the medication room of unit 2 was inspected. The inspection revealed narcotic counts were not being done every shift. The Director of Nursing stated, "The narcotic counts are to be completed every shift." At the time of inspection there were forty two times the narcotic counts should have been completed; five checks were missing. The DON stated, "They are to be done at the change of each shift per our policy." For the month of September there were ninety narcotic checks to be done and four were missed.

The DON provided narcotic counts for the remaining units. The DON stated, "Some of the units may not have had patients on narcotics for certain periods and so the narcotic counts on these units may vary." On unit 6 A, narcotic counts were looked at for the month of August, September, and through October 15, 2012. There were a total of 231 narcotic counts to be done. A total of 7 were not done.
On unit 6 B narcotic counts were looked at from September to October 15, 2012. Out of a possible 138 counts, 3 were missed.
On unit 7 A narcotic counts were looked at for month of September through October 15, 2012. Out of a possible 138 counts, 19 were missed.
Unit 8 narcotic counts for the months of August, September, through October 15, 2012 had a possible 231 narcotic counts during this timeframe, and 36 were not done. The pharmacist stated, "Each unit received a pharmacy audit every month".

An inspection of the emergency drug kit revealed the security seal was intact; the seal was broken to inspect the emergency drug kit. There were two vials of Sodium Bicarbonate and one 10 ml vial of furosomide that was found broken inside the kit. There was broken glass spread around the individual compartments holding the medications.

The MFI asked the pharmacist to inspect the emergency drug box. He hesitated and stated, "It's pretty stuffy in there." MFI asked him to look at the emergency drug box to explain the broken glass. He stated, "It had been dropped. The units crash carts are inspected monthly."

The medication room of unit 2 was then inspected. The inspection revealed narcotic counts were not being done every shift. The DON stated, "The narcotic counts are to be completed every shift." In October, at the time of inspection there were forty two times the narcotic counts should have been completed; five checks were missing. The DON stated, "They are to be done at the change of each shift per our policy." For the month of September there were ninety narcotic checks to be done and four were missed.

The pharmacist stated the last time the Virginia Board of Pharmacy inspected the hospital pharmacy was done April 5, 2012. A copy of this inspection was later provided.

The individual patient medication drawers were also inspected. One patient's medication drawer contained Somatropin 12 mg which had expired October 11, 2012 and an unlabeled insulin pen.

An inspection of the refrigerator on unit 2 revealed a box of Lantus insulin labeled for a Patient #13. Inside that same box was one Novolog pen and two Lantus pens. There were no labels on any of the insulin pens. The pharmacist stated, "She (Patient #6 ) was never on Novolog. I don't know why that's in there". The DON stated, "She (Patient #6) is now on an insulin pump."

On Unit 2 the cabinet that stored medications for emergency after hours use was inspected and revealed the following expired medications:
Two tubes of Pemethrin cream 60g (grams) (2.2 oz) expired September 9, 2012.
One sodium chloride 10 ml (milliliter) vial was stored opened, unknown if accessed
Five Vancomycin 500 mg expired September 1, 2012.
Six Chlorzoxazone 500 mg tabs expired April 2012
Ten tabs of Carbomazepine 100 mg had expired June 2012
One Simethicone 80 mg expired April 2012.

An inspection of Unit six A revealed a Chekstix Combo Pak that is used for urinalysis checks expired August 2012. An inspection of the crash cart emergency drug box on Unit 6 (shared by 6 A and B) revealed the following:
Three vials of Epinephrine 1 mg expired October 1, 2012.
Two 4 ml vials of Levophed expired October 1, 2012
Two vials of 10 ml Furosimide expired October 1, 2012.
Two vials of Dopamine 5 ml that expired August 2012.
The DON and Director of Plant Operations both said they were "dismayed" when commenting on the number of expired medications.

An inspection of Unit seven's crash cart revealed the following:
2 - 2 ml ampoules of Digoxin had expired May 2012
Two vials of Vasopressin 1 ml expired May 2012
One vial of Sodium Chloride 0.9% 10 mls expired July 2012.
Two amps of Solu Medrol 2 ml expired May 2012
Two Furosimide 10 ml vials expired October 1, 2012
One vial of Dopamine 5 ml expired August 2012.
Three vials of Epinephrine 1 ml expired October 1, 2012.
Ventolin inhaler that expired September 2012.

The pharmacist provided copies of the pharmacy audits done on the units from May through September 17, 2012. These audits revealed that each unit was being inspected monthly for expired medications and documented there were none found on any of the units. These audits were discussed with the DON. The DON was unable to clearly point out were the narcotic counts were being monitored.

The Pharmacy & Therapeutics (P&T) committee minutes were reviewed. The policy states the P&T is to meet every quarter. The last documented meeting was March 27, 2012.
A review of the Medical Staff/Medical Executive/Credentialing Committee revealed some pharmacy communication at the June 26, 2012 meeting but no mention of monitoring narcotic counts on the units or the management of outdated drugs. The Quality minutes were reviewed and the Director of Quality was asked how the pharmacy ties in to the Quality meetings. The Director of Quality was unable to demonstrate or provide data to substantiate that this pharmacy piece is being done consistently or at all.

Based on observations,staff interviews, and review of Pharmacy logs, the hospital pharmacy failed to demonstrate a safe and organized method to ensure the control and distribution of patient medications.

The findings include:


A tour of the hospital with the Director of Nursing (Employee #3) and the Director of Plant Operations (Employee #5) was completed on 10/15/12. Unit 2's emergency crash cart had an emergency drug kit sitting on top of the cart. As the MFI began checking the crash cart log book it revealed that in the last 15 day period the crash cart had not been checked 5 of those days. Staff member #3 stated, " It (crash cart) is to be checked daily."

An inspection of the emergency drug kit revealed the security seal was intact; but when the seal was broken to get into the emergency drug kit, the MFI had difficulty opening the plastic kit lid. There were two vials of Sodium Bicarbonate and one 10 ml vial of furosomide that was found broken inside the kit. There was broken glass spread around the individual compartments holding the medications.

The medication room of unit 2 was then inspected. The inspection revealed narcotic counts were not being done every shift. The DON stated , "The narcotic counts are to be completed every shift." In October, at the time of inspection there were forty two times the narcotic counts should have been completed; five checks were missing. The DON stated, "They are to be done at the change of each shift per our policy." For the month of September there were ninety narcotic checks to be done and four were missed.

The DON provided narcotic counts for the remaining units. The DON stated, "Some of the units may not have had patients on narcotics for certain periods and so the narcotic counts on these units may vary."
On unit 6 A, narcotic counts were looked at for the month of August, September, and through October 15, 2012. There were a total of 231 narcotic counts to be done. A total of 7 were not done.
On unit 6 B narcotic counts were looked at from September to October 15, 2012. Out of a possible 138 counts, 3 were missed.
On unit 7 A narcotic counts were looked at for month of September through October 15, 2012. Out of a possible 138 counts, 19 were missed.
Unit 8 narcotic counts for the months of August, September, through October 15, 2012 had a possible 231 narcotic counts during this timeframe, and 36 were not done. The pharmacist stated during the tour, "Each unit received a pharmacy audit every month".

The pharmacist provided copies of the pharmacy audits done on the units from May through September 17, 2012. These audits revealed that each unit was being inspected monthly for expired medications and documented there were none found on any of the units. These audits were discussed with the DON. The DON was unable to clearly point out were the narcotic counts were being monitored. The MFI commented that the audits did not appear to be accurate or reliable, the DON agreed.

Based on observation and interviews with staff the hospital pharmacy failed to ensure that outdated or unusable medications were not available for patient use.

The findings include:

An inspection of the emergency drug kit revealed the security seal was intact; the seal was broken to inspect the emergency drug kit. There were two vials of Sodium Bicarbonate and one 10 ml vial of furosomide that was found broken inside the kit. There was broken glass spread around the individual compartments holding the medications.

The MFI asked the pharmacist to inspect the emergency drug box. He hesitated and stated, "It's pretty stuffy in there." MFI asked him to look at the emergency drug box to explain the broken glass. He stated, "It had been dropped. The units crash carts are inspected monthly."

The pharmacist stated the last time the Virginia Board of Pharmacy inspected the hospital pharmacy was done April 5, 2012. A copy of this inspection was later provided.

The individual patient medication drawers were also inspected. One patient's medication drawer contained Somatropin 12 mg which had expired October 11, 2012 and an unlabeled insulin pen.

An inspection of the refrigerator on unit 2 revealed a box of Lantus insulin labeled for a Patient #13. Inside that same box was one Novolog pen and two Lantus pens. There were no labels on any of the insulin pens. The pharmacist stated, "She (Patient #6 ) was never on Novolog. I don't know why that's in there". The DON stated, "She (Patient #6) is now on an insulin pump."

On Unit 2 the cabinet that stored medications for emergency after hours use was inspected and revealed the following expired medications:
Two tubes of Pemethrin cream 60g (grams) (2.2 oz) expired September 9, 2012.
One sodium chloride 10 ml (milliliter) vial was stored opened, unknown if accessed
Five Vancomycin 500 mg expired September 1, 2012.
Six Chlorzoxazone 500 mg tabs expired April 2012
Ten tabs of Carbomazepine 100 mg had expired June 2012
One Simethicone 80 mg expired April 2012.

An inspection of Unit six A revealed a Chekstix Combo Pak that is used for urinalysis checks expired August 2012. An inspection of the crash cart emergency drug box on Unit 6 (shared by 6 A and B) revealed the following:
Three vials of Epinephrine 1 mg expired October 1, 2012.
Two 4 ml vials of Levophed expired October 1, 2012
Two vials of 10 ml Furosimide expired October 1, 2012.
Two vials of Dopamine 5 ml that expired August 2012.
The DON and Director of Plant Operations both said they were "dismayed" when commenting on the number of expired medications.

An inspection of Unit seven ' s crash cart revealed the following:
2 - 2 ml ampoules of Digoxin had expired May 2012
Two vials of Vasopressin 1 ml expired May 2012
One vial of Sodium Chloride 0.9% 10 mls expired July 2012.
Two amps of Solu Medrol 2 ml expired May 2012
Two Furosimide 10 ml vials expired October 1, 2012
One vial of Dopamine 5 ml expired August 2012.
Three vials of Epinephrine 1 ml expired October 1, 2012.
Ventolin inhaler that expired September 2012.

During the tour the facility pharmacist (Employee #6) was called to the unit. The pharmacist stated, "The last Board of Pharmacy inspection for the hospital pharmacy was April 5, 2012." A copy of the inspection report was requested and revealed the pharmacy was cited deficiencies for repackaging drugs that were "labeled with an expiration date exceeding the expiration date of the stock bottle".