HospitalInspections.org

Based on Document review, observation and interview with key personnel on November 5, 2013 at approximately 1500 hours, the facility failed to furnish services in accordance with appropriate written policies.

Findings include:
1. The following was found during an inspection of the anesthesia cart in Operating Room 2:
a. One syringe labeled "Atropine 0.4 mg/ml" failed to be labeled with the date the syringe was filled, signature of the person who filled the syringe and the expiration date.
b. One syringe labeled "Ephedrine 10 mg/ml" failed to be labeled with the date the syringe was filled, signature of the person who filled the syringe and the expiration date.
c. One syringe labeled "Succinocholine" failed to be labeled with the dose, the date the syringe was filled, signature of the person who filled the syringe and the expiration date.
d. One opened multidose vial labeled "Propofol" failed to be labeled with the date the vial was opened and the expiration date.
e. One opened multidose vial labeled "Xylocaine" failed to be labeled with the date the vial was opened and the expiration date.
f. At the time of the discovery the CRNA stated "I think they were here this morning... I was taught concentration, date, time and initial."
g. The facility Medication Handling, Administration and Documentation Policy states "Multidose vials are dated with the date opened and initialed when opened..."
h. The facility "Medications in the Anesthesia Department" Policy states, "All medications used by anesthesia will be in a labeled syringe."
i. The facility "Packaging and Labeling of Medications" Policy states, "At a minimum the labeling must include drug name, strength, amount..., expiration date..."
j. These finding were immediately confirmed by the Surgical Services Director.

See tag C-271 regarding pharmaceutical services being administered in accordance with established hospital policies.

Based on document review and interview with key personnel on November 6, 2013, it was determined that the facility failed to provide the swing bed patients with a written notice of discharge.
Findings include:
1. A review of discharged swing bed patient medical records was conducted. Two of two (2 of 2) records (records C and E) revealed that the facility failed to provide written notice to the patient that included the elements required in this regulation.
2. During an interview with the Med-Surg/Swing Bed/ICU Manager at 9:30, she reported that the "Notice of Right To Appeal Discharge Letter is only given to patients who appeal their discharge, and that the QIO had assisted the hospital in interpreting the hospital regulations."
3. During an interview at 10:30, the Director of Quality and Patient Safety stated "We have reviewed the Regs... You are absolutely right. We misinterpreted the Regs... We can fix this today..."

Based on Document review, observation and interview with key personnel on November 5, 2013 at approximately 1500 hours, the facility failed to furnish services in accordance with appropriate written policies.

Findings include:
1. The following was found during an inspection of the anesthesia cart in Operating Room 2:
a. One syringe labeled "Atropine 0.4 mg/ml" failed to be labeled with the date the syringe was filled, signature of the person who filled the syringe and the expiration date.
b. One syringe labeled "Ephedrine 10 mg/ml" failed to be labeled with the date the syringe was filled, signature of the person who filled the syringe and the expiration date.
c. One syringe labeled "Succinocholine" failed to be labeled with the dose, the date the syringe was filled, signature of the person who filled the syringe and the expiration date.
d. One opened multidose vial labeled "Propofol" failed to be labeled with the date the vial was opened and the expiration date.
e. One opened multidose vial labeled "Xylocaine" failed to be labeled with the date the vial was opened and the expiration date.
f. At the time of the discovery the CRNA stated "I think they were here this morning... I was taught concentration, date, time and initial."
g. The facility Medication Handling, Administration and Documentation Policy states "Multidose vials are dated with the date opened and initialed when opened..."
h. The facility "Medications in the Anesthesia Department" Policy states, "All medications used by anesthesia will be in a labeled syringe."
i. The facility "Packaging and Labeling of Medications" Policy states, "At a minimum the labeling must include drug name, strength, amount..., expiration date..."
j. These finding were immediately confirmed by the Surgical Services Director.

See tag C-271 regarding pharmaceutical services being administered in accordance with established hospital policies.

Based on document review and interview with key personnel on November 6, 2013, it was determined that the facility failed to provide the swing bed patients with a written notice of discharge.
Findings include:
1. A review of discharged swing bed patient medical records was conducted. Two of two (2 of 2) records (records C and E) revealed that the facility failed to provide written notice to the patient that included the elements required in this regulation.
2. During an interview with the Med-Surg/Swing Bed/ICU Manager at 9:30, she reported that the "Notice of Right To Appeal Discharge Letter is only given to patients who appeal their discharge, and that the QIO had assisted the hospital in interpreting the hospital regulations."
3. During an interview at 10:30, the Director of Quality and Patient Safety stated "We have reviewed the Regs... You are absolutely right. We misinterpreted the Regs... We can fix this today..."