HospitalInspections.org

Based on observation, policy/procedure review and staff interviews, the hospital failed to ensure expired drugs were not available for patient use. This was evidenced by having expired medications in the Adverse Reaction Drug Tray located in the Radiology Department. Findings.

An observation in the CT-Scan Room of the Radiology Department on 03/05/14 at 1:30 p.m., revealed a tackle box labeled "X-Ray Reaction Tray" with a silver removable seal. The tray was noted to contained the following expired drugs:
Diphenhydramine 50mg (milligram)/ml (milliliter) (3) expired 11/2013.
Isuprel 1:5000 1mg (0.2mg/ml) (3) expired 11/13.
Dopamine 400mg/5ml (80mg/ml) (1) expired 12/13.
Dexamethasone 4mg/ml (1) expired 12/13.
Epinephrine 1:10,000 1mg (0.1mg/ml) (1) expired 11/13.
S12 Radiology Director confirmed the above findings at the time of the observation.

Review of the Hospital policy/procedure titled "Reaction to Contrast Medium" presented by S4 Administrative Assistant as current (10/95) policy reads in part: 2. A reaction kit is to be immediately available. 8. Be familiar with emergency treatment and have necessary drugs and equipment readily available."

Review of the Hospital policy/procedure titled "Pharmacy-Unit Inspections" presented by S4 Administrative Assistant as current (01/2010) policy reads in part: " Policy- Areas where medications are stored within the hospital will be inspected monthly and a written record kept of the inspection and findings. Procedure- At least once each month, the pharmacist or their designee will perform inspection of all areas where medications are stored. C. Any medication not in-date will be removed from stock and return to pharmacy for destruction."

In an interview on 03/05/14 at 1:35 p.m.,S12 Radiology Director indicated that he was not aware of the drugs being in the Radiology Department and therefore was not certain who was responsible for inventorying the drugs.

In an interview on 03/05/14 at 1:40 p.m., S13 Radiology Technician indicated that she periodic checked the tray and replaced outdated drugs as needed. S13 Radiology Technician indicated that no documented log was maintained on the reaction tray.

In an interview on 03/06/14 at 9:30 a.m., S8 Pharmacist indicated the drugs should have been inventoried, the expired drugs removed and not be available for patient use.

Based on record review and interviews the hospital failed to provided social services in order to attain and/or maintain the swing bed patients' highest practicable physical, mental and psychosocial well being as evidenced by the contract social worker only doing retrospective chart reviews after the patients are discharged from the hospital and not assessing or meeting with the patients and the patients' families while they are in the hospital.
Findings:

Review of the hospital's policy on Social Services for the Swing bed patients revealed, "The hospital will provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each patient."

Review of the Swing Bed Department QI (Quality Improvement) Review form revealed a form with a list of areas to audit the Swing Bed Patients' medical records after the patients were discharged.

Review of Patient #19's medical record revealed she was admitted to the hospital to a swing bed on 2/19/14 and discharged on 2/26/14 with the diagnoses of Anemia, Urinary Tract Infection, and Clostridium Difficile Colitis. Further review of her medical record revealed no evidence of a social worker assessing or meeting with the patient or her family while she was in the hospital.

A telephone interview was conducted on 3/7/14 at 10 a.m. with S14Social Worker. S14Social Worker reported her job duties entailed reviewing the swing bed patients' medical records after they were discharged from the hospital to make sure all areas of need were addressed by the hospital staff. She also reported she fills out the form titled Swing Bed Department QI review on all the Swing bed patients' medical record. S14Social Worker reported she does not assess or interview the patients while they are in the hospital, her chart review is retrospective.

An interview was conducted with S2Director of Nurses on 3/7/14 at 10:15 a.m. She reported the hospital has always utilized the contract social worker in this capacity for the swing bed patients.