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Based on observation, interview, and document review, the facility failed to ensure all medications were secured in the Intensive Care Unit (ICU), Emergency Department (ED), and 2 of 3 hospital outpatient clinics reviewed. This had the potential to effect all patients who received care in the ICU, ED, and the two outpatient clinics.

Findings include:

On 9/28/15, at 2:30 p.m. 2 drawers of the identified crash cart medications (used during cardiopulmonary resuscitation, the process of intervening in death and near death episodes) were observed on top of the Omnicell (computerized medication dispenser). The Omnicell was located behind the nurses station, however, it was easily accessible to patients and visitors. The multiple drawers were covered in cellophane, but were not secured by lock or computer lock.

The small drawer contained medications as follows:

Adensosine 6 milligram (mg)/2 milliliter (ml) (3 vials)
Amiodarone 150 mg/3 ml (3 vials)
Atropine 1 mg/10 ml (4 injection syringes)
Calcium Chloride 1 gram (G)/10 ml (2 vials)
Dextrose 25 G/50 ml (1 injection syringe)
Epinephrine 1:10,000 10 ml syringe (5 injection syringes)
Lidocaine 100 mg/5 ml syringe (2 injection syringes)
Naloxone 0.4 mg/1 ml (2 vials)
Magnesium Sulfate 1 gm/2 ml (2 vials)
Norepinephrine (Levophed) 4 mg/4 ml (1 vial)
Solium Bicarbonate 50 miliequivalents (mEg) (2 injection syringes)
Sodium Chloride 0.9% 10 ml syringe flush (15)
Vasopressin 20 Units/ml (2 vials)
Verapamil 5 mg/2 ml (2 vials)

The large drawer contained medications as follows:

Dobutamine 500 mg/250 ml bag
Dopamine 500 mg/250 ml bag
Lidocaine 2 G/500 ml bag
Nitroglycerin 100 micrograms (mcg)/ml 25 mg/D5W (5% sugar water solution) 250 ml bottle
Albuterol Multidose inhaler (MDI)
Albuterol 3 ml unit dose intermittent positive pressure breathing
Ipratropium 2.5 ml unit dose intermittent positive pressure breathing

The same medications as what were identified in the ICU (listed above) were observed on 9/28/15, at approximetly 2:45 p.m. on top of the emergency department Omnicell. The Omnicell was located behind the nurses desk, however, the medication room door was not secured, staff was not always at the desk, and the tray could easily have been taken and/ or accessed by patients, visitors, and unauthorized personal.

During interview on 9/28/15, at 3:00 p.m. the clinical pharmacist in ICU and the ICU director stated the medications sitting on top of the Omnicell were not secure.

During interview on 9/29/15, at 8:00 a.m. registered nurse (RN)-B stated the drawers had been picked up by pharmacy, and the drawers were no longer observed sitting on top of the Omnicell.

During interview on 9/30/15, at 1:30 p.m. the director of pharmacy stated he was not aware the additional crash cart drawers were left in ICU and ED, and stated the medications were not secure sitting on top of the Omnicell's.



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During tour of the Lakes Urology Clinic on 9/19/15, at 11:20 a.m. with surgery operations manager (SOM) the medication cabinet was observed secured with a magnet lock. Staff at the clinic opened the medication cabinet with a magnet, and when staff were done with the medication cabinet it was closed and the medication cabinet locked magnetically. The staff put the magnet on a metal basket sitting on the counter.
A list of medications stored in Lakes Urology Clinic medication cabinet included the following:
· Cipro (antibiotic) 500 milligram (mg) tablets
· Trimethoprim (treats urinary tract infections) 100 mg tablets
· Macrobid (antibiotic) 100 mg tablets
· Lidocaine 1% 10 milliliter (ml)/ 20 ml vials
· Sodium Bicarbonate 50 ml
· Iodine Solution 3 ounces (oz.)

During a tour of the Pequot Lakes Clinic on 9/29/15, at 2:58 p.m. with licensed practical nurse (LPN)-A the medication cabinets were opened by LPN-A with a magnet that unlocked the medication cabinets. When LPN-A finished with the medication cabinet, LPN-A closed the medication cabinet and the medication cabinet locked magnetically. LPN-A put the magnet in an unlocked drawer in the nursing station.
A list of medications stored in the Pequot Lakes Clinic medication cabinet included the following:
· Acetaminophen 80 mg chewable tablets
· Atropine Sulfate 1 mg/10 ml syringe
· Ceftriaxone Injection 1 gram vial
· Epinephrine 1:10000 syringe
· Furosemide Injection 20 mg/2 ml vial
· Duoneb Solution
· Lidocaine 1% with Epinephrine 1:100000 20 ml vial
· Solu-Medrol 125 mg
· Vitamin K Injection 10 mg/ml
During interview on 9/30/15, at 3:00 p.m. director of ambulatory care (DAC) stated the magnets are stored in a drawer afterhours at the nurse's station. The DAC stated the drawers were not locked, and afterhours housekeeping and a courier service have access to the clinics.
During interview on 10/1/15, at 8:15 a.m. director of pharmacy (DP) stated the magnet locks should not be used as locks to secure medications. DP stated the magnetic lock is not secure and there should be other means to lock the medication cabinets to ensure medications are secured.
The facility policy titled Storage of Pharmaceuticals policy dated 10/11, indicated "Narcotics shall be secured", but lacked direction for the secure storage of all medications within the hospital units and clinics. The director of pharmacy stated the policy was inadequate and was one of approximately 20 policies left to be reviewed and revised.

Based on observation and interview, the hospital was found to be out of compliance with Life Safety Code requirements. These findings had the potential to affect all patients in the hospital.

Findings include:

Please refer to Life Safety Code inspection tag K-0029, K-0046, K-0052, and K-0056.

Based on interview and document review, the facility failed to ensure all patient care staff were provided education on organ donation protocols for 4 of 12 (SW-A, PT-A, OT-A, ST-A) employee records reviewed for training.

Findings include:

During review of employee personnel and training records on 9/30/15, it was noted that social worker (SW)-A, physical therapist (PT)-A, occupational therapist (OT)-A, and speech therapist (ST)-A had not received training on the protocols for the process of organ donation.

During interview on 9/30/15, at 1:40 p.m. the chief nursing officer stated the hospital only trained inpatient nursing staff, nursing assistants, physicians, surgical technicians, and emergency room technicians. The chief nursing officer stated social workers, physical therapists, occupational therapists, and speech therapists do not receive training on organ donation procedures and protocols.