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At the time of the revisit on 06/04 and 05/2014, this deficiency was not corrected.

Based on review of hospital documents, surveyor observations and interviews with hospital staff, the hospital failed to ensure that the hospital's pharmaceutical services performed appropriate oversight of medications.

Findings:

1. While the hospital had changed their practice at the offsite surgery center and started using single use prefilled syringes for buffered Lidocaine, this did not happen at the main campus surgery area.

2. On the afternoon of 06/04/2014, the surveyors toured the main campus endoscopy area. In the medication refrigerator was a 50 milliliter vial of buffered Lidocaine. The pharmacist told the surveyors that the buffered Lidocaine was now prepared in the hospital's pharmacy for main campus departments (Specifically mentioned was main campus departments of surgery endoscopy and emergency services). He stated every Wednesday new buffered Lidocaine vials would be delivered and the past week's vials would be discarded.

3. The surveyor confirmed with the endoscopy nurse that each patient received intravenous (IV) access and that the buffered Lidocaine was used in increments of one tenth (0.10) of a milliliter increments on patients prior to starting the IVs or saline locks.

4. On the morning of 06/05/2014, review of the past weeks' surgery schedule (05/27/2014 through 06/03/2014 for the main campus endoscopy unit showed 60 cases were performed. Each entry into the septum is added risk/opportunity for contaminates to be entered into the solution. During the week of 05/27/2014 to 06/03/2014, the septum of the buffered Lidocaine could have been entered 60 times.

At the time of the revisit on 06/04 and 05/2014, this deficiency was not corrected.

Based on observation and staff interview, it was determined that the hospital failed to ensure all medications in the surgery department were secured at all times.

Findings:

1. On 06/04/2014, endoscopy staff told the surveyors that medication was used for only one patient and any remainder would be discarded after each case.

2. Surveyor observations of the main campus endoscopy department on the afternoon of 06/04/2014, showed a locked drawer in Room 2 contained used vials of medications. Some still contained medication.

3. Hospital staff confirmed the above observation at the time.

At the time of the revisit on 06/04 and 05/2014, this deficiency was not corrected.

Based on document review and staff interview, the hospital failed to ensure all areas where surgical services were provided followed the same governing policies.

Findings:

The infection control practitioner stated in an interview on 06/04/14, Cavicide Wipes were used to clean the endoscopy suites, unless the patient has diarrhea or documented diagnosis of Clostridium Difficile.

In an interview with the director of the offsite surgical center, she stated Clorox Wipes were used to clean the endoscopy suites. This was not the same practice being performed at the main campus endoscopy center.

Medication procedures are not uniform throughout the surgical departments (main campus and off site surgery center). See Tag A-0491 for details.