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Based on review of policy/procedure, observation, and staff interview, the Critical Access Hospital (CAH) failed to maintain control over medications in all CAH locations, including floor stock.

Findings include:

Review of the policy/procedure that included management of outdated drugs revealed that pharmacy personnel were to remove outdated narcotic drugs and that the nursing staff was to remove regular outdated medications.

On 07/24/12 during Unit A Surveillance, observation in the Medication Room revealed three (3) medications which were outdated and/or not labeled when opened. The medications were Dexamethasone, Travatan, and another medication which had been thrown away before the name was recorded. Four multi dose vials were not dated when opened, or outdated. Also, the temperature of the medication refrigerator was not being checked and recorded daily.

On 7/25/12 during Emergency Department Surveillance,observation in the Medication Room revealed that the medication Pepcid was dated 02/18 12 when opened, and Cardizem was not dated when opened. A small bag of 0.9% Sodium Chloride, used for flushing, was found on a table in the main trauma room not dated when opened.


On 07/25/12 at approximately 11:15 a.m. an interview with an Emergency Department Licensed Practical Nurse (LPN) and a Pharmacy Technician was held in the Pharmacy. They both stated that it was their practice to pull the narcotic medications when outdated and place them in the vault. They are then picked up by Pharmaceutical Services Care twice a year. The nurses on the unit dispose of the other outdated medications.

Based on review of medical records, the Critical Access Hospital (CAH) failed to ensure that all consent forms were being timed and dated.


Findings include:


1. 17 medical records were selected at random from a list of discharges from January 1, 2012, though June 30, 2012, and reviewed along with 11 inpatient medical records for a total of 28 medical records.


2. One (1) of two (2) records reviewed, that contained consents for the administration of IntraVenous contrast for a procedure, revealed that the consent form had not been dated when signed.


3. One (1) of one (1) records reviewed with a no code consent, revealed that the consent had not been time when signed.

Based on review of medical records, the Critical Access Hospital (CAH) failed to ensure that all entries in the medical record had been timed.


Findings include:


1. 17 medical records were selected at random from a list of discharges from January 1, 2012, though June 30, 2012, and reviewed along with 11 inpatient medical records for a total of 28 medical records.


2. On 22 of 28 medical records reviewed, the handwritten history and physical examination had not been timed by the physician documenting the history and physical.


3. On nine (9) of 28 medical records reviewed, the physician had not timed all progress notes he had written in the medical record.


4. On 15 of 28 medical records reviewed, all physician orders had not been timed when entered into the medical record. This included orders written by the physician, verbal orders taken by a nurse, and clarification orders written by other disciplines.