HospitalInspections.org

Based on observation, interview, and policy review, the provider failed to ensure:
*Unauthorized persons did not have access to medications and biologicals stored in three of four observed patient care areas (emergency room, radiology room, and endoscopy suite).
*Expired biologicals and treatment packages were removed for patient use in one of four observed patient care areas (emergency room). Findings include:

1. Observation in the emergency room on 3/29/10 at 2:45 p.m. revealed:
*There were two doors to the room.
*The above doors were open and had no locking mechanisms.
*An unlocked cabinet on the south wall contained 37 different intravenous (IV) solution bags.
*An unlocked north cabinet in the emergency room had Fleet enemas and a respiratory emergency kit with epinephrine, Solu-Medrol, Benadryl, Zantac, and aminophylline in it.
*The north cabinet had a container with several envelopes in it with 21 different medications in the envelopes.
*The north cabinet contained 13 different vials of medications and 30 pre-filled syringes of biologicals.
*The unlocked refrigerator in the emergency room contained vials of tuberculin solution, Cardizem, and Integrelin bolus.
*An unlocked portable travel kit contained four IV solutions and prefilled atropine, lidocaine, and epinephrine syringes.

Interview with the director of nursing (DON) at the time of the above observation of the emergency room revealed the above medications and biologicals were stored in locked cabinets. The emergency room doors did not have locks and were always kept open when not in use. The DON confirmed the medications and biologicals were accessible to unauthorized personnel and the general public.

Interview with the consultant pharmacist on 3/30/10 at 8:35 a.m. confirmed the above medications and biologicals in the emergency room were accessible to unauthorized personnel and the general public. He stated he only checked the crash cart monthly for outdated medications and being locked.

2. Observation of the radiology room on 3/29/10 at 4:25 p.m. revealed the room had no locks on the doors. Further observation revealed there were 27 containers of barium sulfate suspension in the unlocked cabinet and on the counter in the radiology room. Interview with the radiology technician at that time revealed the above biologicals were accessible to unauthorized personnel and the general public.

3. Observation of the entrance area to the endoscopy suite on 3/30/10 at 2:35 p.m. revealed a metal cart with a total of 88 IV solutions on it. The door to that room did not have a lock. Interview with the DON at the time of the observation confirmed the door did not lock. The area was accessible to unauthorized personnel and the general public.

4. Observation of the emergency room on 3/29/10 at 2:45 p.m. revealed 7 expired IV solutions and 13 expired pediatric emergency system packages. Interview with the DON at that time confirmed the expired items needed to be removed. She thought the IV solutions were monitored for expiration dates since the medications were monitored for outdates.

Review of the pharmacy policy and procedures preface dated 11/10/82 revealed "It is the policy of the hospital to provide the best possible pharmacy service to its patients and to abide by all applicable state and federal laws and regulations."

Review of the procurement of medication pharmacy policy dated 12/20/06 revealed "The consulting pharmacist shall be responsible for maintenance and the supply as well as assuring that all drugs are properly labeled and stored."

Based on record review, interview, and medical staff bylaws review, the provider failed to ensure all sampled medical record entries from different patient service areas were authenticated with signatures, dates, or times. A sample of 287 medical record entries revealed 197 instances where either the signature, date, or time of the entry was not recorded. Findings include:

1. Review of 89 written physicians' orders during review of medical records on all patient care areas revealed 1 was not signed, 1 was not dated, and 30 were not timed.

2. Review of 132 physicians' progress notes during review of medical records on all patient care areas revealed 5 were not signed, 6 were not dated, and 102 were not timed.

4. Review of 48 miscellaneous forms regarding physician or staff contact with the patient during review of medical records on all patient care areas revealed 3 were not signed, 18 were not dated, and 31 were not timed.

5. Interview with the director of nursing at 3:00 p.m. on 3/30/10 revealed she was aware all entries should have been signed, dated, and timed. She stated she reviewed all charts and had determined timing of entries to be a concern. She revealed the provider did not have a policy addressing the need to sign, date, and time all entries in the medical record.

Review of the provider's 8/4/08 medical staff bylaws revealed all entries in the medical record should have been signed and dated by the responsible physician. Nothing was found in those bylaws that indicated all medical record entries must also be timed.

Based on record review and interview, the provider failed to ensure five of five sampled swing bed patients (1, 2, 3, 19, and 20) were:
*Informed in writing of their patient rights as swing bed patients.
*Asked to acknowledge receipt of patient rights with a signature.
Findings include:

1. Review of medical records for patients 1, 2, 3, 19, and 20 revealed:
*There was no documentation to indicate they had been provided a written copy of their rights as swing bed patients.
*There was no signature page to show they had acknowledged receiving a written copy of their rights as swing bed patients.

Review of the provider's swing bed policies revealed an undated form titled Swing bed participant's bill of rights. The form outlined the specific rights of swing bed patients and included a space for the signature of the swing bed patient or representative to acknowledge receipt of the form.

Interview on 3/31/10 at 9:00 a.m. with the director of nursing revealed the provider:
*Only offered swing bed patients the same patient bill of rights other hospital patients received.
*Did not ask any patients to sign an acknowledgment showing receipt of the bill of rights.
*Did not use the swing bed participant's bill of rights included in the swing bed policies.