HospitalInspections.org

Based on observation and interview, the hospital failed to ensure expired drugs and biologicals were discarded and no longer in use for all patients.

Findings:

During an observation on 09/11/2024 at 10:00 am, the below listed items were observed to be expired:
1. Sodium Chloride inhalation solution expired 03/2024
2. Prochlorperazine Edisylate expired 08/2024

During an interview with Staff #1 on 09/11/2024 at 10:00 am, Staff 1 stated the staff should be checking for expired supplies and the sodium chloride and prochlorperazine edisylate were expired.

Based on a review of records and interview, the hospital failed to update their policies and procedures for all patients and staff.

Findings:

A review of administrative documents showed the following policies and procedures last reviewed on:

1. EMTALA-Medical Screening Policy last updated 2005
2. EMTALA Central Log Policy last updated 2005
3. EMTALA Stabilization Policy last updated 2005
4. EMTALA Transfer Policy last updated 2005
5. Precipitous Delivery Policy last updated 2005

On 09/11/2024 at 3:00 pm, Staff I, H and K stated:
1. the hospital failed to update their policies and procedures timely and
2. there was no policy on how often policies should be reviewed and updated.

Based on a review of records and interview, the facility failed to ensure the accuracy, legibility and completeness of the medical record for one (Pt # 2) of twenty records.

Findings

Pt #2
A review of the medication orders showed instructions to:
1. Give Demerol 50 (g or mg) illegible
2. Give pheno... illegible 50 (g or mg) illegible

Documentation showed no date, time, or route, no evidence if the orders were verbal or written orders, no verification that the orders were verified by the nurse, and no signature or time by the ordering provider.


On 09/12/2024 at 2:20 pm, Staff H stated:
1. The hospital failed to ensure the Accuracy, Legibility and Completeness of the medical record.

Based on a record review and interview, the hospital failed to ensure their QAPI program contained measures for patient care and satisfaction for 20 (Pt 1-20) of 20 patients review reviewe, potentially affecting all patients and staff.

Findings:

A review of QA records showed no periodic review of all services provided, no review of medication errors, and no review of patient care, and no review of patient satisfaction.

On 09/12/24 at 240 pm, Staff H, I, J stated the QA records showed no documentation related to patient care or patient satisfaction.