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Based on observation, +interview and record review, the facility failed to monitor and remove expired or outdated emergency medications from patient care areas in the Emergency Department (ED). This had the potential to affect all patients who are treated in the facility's ED. The hospital census was one when the survey began.

Record review of policy titled, "Emergency Room Services Cleaning and Inventory", dated 10/12/10 showed that medication and supply outdates are to be checked twice a month (page 1, #2.g).

1. Observation on 03/03/11 at 11:55 AM, showed that ED Patient Bay #2 contained the following outdated emergency medications:
-three Lidocaine 2% (for treatment cardiac emergencies) injections, Lot #75-407-DK, expired 03/01/11;
-two Phenytoin Sodium (for treatment of seizures) injections, Lot #81-0349-EV, expired 03/01/11.

2. Observation on 03/03/11 at 12:10 PM, showed that ED Patient Bay #3 contained the following outdated emergency medications:
-four Lidocaine 2% injections, Lot #75-407-DK, expired 03/01/11;
-two Phenytoin Sodium injections, Lot #81-0349-EV, expired 03/01/11.

3. Observation on 03/03/11 at 12:25 PM, showed that ED Patient Bay #1 contained the following outdated emergency medications:
-two Lidocaine 2% injections, Lot #75-407-DK, expired 03/01/11;
-two Phenytoin Sodium injections, Lot #81-0349-EV, expired 03/01/11.

During an interview on 03/03/11 at 12:35, Staff A, ED RN (Registered Nurse) confirmed the outdated medications and stated that the night nurse scheduled in the ED is responsible for removing outdated medications from the medication drawers every two weeks. Staff A stated that the medications in the drawers are considered crash cart drugs (medications that would be used during a medical emergency).

During an interview on 03/03/11 at 1:00 PM, Staff B, Director of Patient Care confirmed the medications were expired in the ED.

Based on record review and interview, the facility failed to follow policy and ensure physicians' orders were signed, dated, and timed within 48 hours, for three patient medical records (#4, #1, and #8) out of six records reviewed. This had the potential to affect all patients in the facility. The facility census was one when the survey began.
Record review of the facility "Rules and Regulations" dated 10/20/10 showed that all orders shall be signed, dated, and timed by the responsible physician within 48 hours.
Record review of policy titled, "Nursing Department Physician Orders", dated 10/20/10 showed that telephone and verbal orders must be signed, timed, and dated by the ordering physician within 48 hours (page 1 - 2.b.2 and 2.c.2).
1. Record review of discharged Patient #4's medical record showed the following:
-a physician order for life sustaining treatment (to continue treating a patient if their heart or breathing stops), ordered on 11/16/10, was not signed by the physician until 01/15/11 at 2:00 PM;
-telephone orders dated 11/16/10 at 4:10 PM were signed, but not dated or timed by the physician.

2. Record review of discharged Patient #1's medical record showed the following:
-verbal orders written on 02/21/11 at 2:30 PM were signed, but not dated or timed by the physician;
-verbal orders written on 02/21/11 at 12:00 PM, were not signed, dated, or timed by the physician.

3. Record review of current Patient #8's medical record showed the following:
-a verbal order written on 02/22/11 at 8:55 AM was signed, but not dated or timed by the physician;
-a protocol order written on 02/22/11 at 6:00 PM was signed, but not dated or timed by the physician;
-a telephone order written on 02/25/11 at 4:30 PM, was not signed by the physician;
-telephone orders written on 02/27/11 at 5:50 PM, were not signed by the physician.

Record review of the facilities Quality Improvement (QI) Monitoring for Physicians' Signatures showed the following:
-11/16/10 all orders were signed;
-11/17/10 all orders were signed;
-02/21/11 all orders were signed;
-02/22/11 all orders were signed;
-02/23/11 all orders were signed;
-02/25/11 all orders were flagged;
-02/26/11 all orders were signed;
-02/27/11 all orders were flagged;
-02/28/11 all orders were signed.

During an interview on 03/03/11 at 3:15 PM, Staff B, Director of Patient Care confirmed that the QI Monitoring for Physicians' Signatures does not indicate whether the physicians are signing, dating, or timing the orders within 48 hours.




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