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Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure the removal of outdated medications from 1 of 1 radiology drug storage area (computed tomography scanning area). Failure to remove outdated medications from the department's emergency kit may result in patients receiving expired and ineffective medications.

Findings include:

Observation on 4/23/19 at 10:30 a.m. of the radiology CT scanning area showed a lockbox contained two epinephrine pens expired February 2019. During the observation, a radiology staff member (#1) stated staff had failed to identify and have pharmacy replace the two expired pens and indicated the department had no policy or procedure to routinely monitor and identify expired pens.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to follow infection control practices for 2 of 4 patients (Patient #22 and #23) observed receiving medications. Failure to follow established infection control practices related to medication administration may allow transmission of organisms and pathogens from staff to patients and from one environment to another.

Observations showed the following:
- 04/22/19 at 11:36 a.m., a nurse (#4) carried a glucometer supply caddy into Patient #22's room, placed the caddy on the bed side table, exited the room and placed the caddy on the medication cart. The nurse (#4) then placed the caddy in storage without cleaning it.
- 04/22/19 at 11:45 a.m., a nurse (#4) entered Patient #22's room with a Novolog (insulin) pen, administered the insulin, placed the Novolog pen in her scrubs pocket, returned to the medication cart, removed the pen from her pocket, and placed it in the medication cart without cleaning it.
- 04/22/19 at 11:50 a.m., a nurse (#4) removed the glucometer supply caddy from the medication room, placed it on a table in the activity room, checked the glucose of Patient #23, and returned the caddy to the medication room without cleaning it.
- 04/22/19 12:07 p.m., a nurse (#4) removed a vile of Humalog (insulin) from the medication fridge, prepared the insulin for administration, and placed the syringe on a visibly soiled medication tray. During the medication administration, the nurse placed the tray on an unclean surface in the soiled utility room and then placed the medication tray back on the medication cart without cleaning it.

Upon request, on 04/23/19, the CAH failed to provide a policy regarding cleaning of the medication tray and glucometer supply caddy.

During interview at 3:45 p.m. on 04/23/19, administrative nursing staff members (#2 and #3) stated they expected nursing staff to clean medication trays and the glucometer supply caddy after each use.

Based on record review, review of facility policy, and staff interview, the Critical Access Hospital (CAH) failed to assess the effectiveness of medications given to patients on an as needed (PRN) basis within the expected timeframe for 7 of 13 patient records reviewed (Patients #4, #5, #8, #9, #13, #17, #19) who received PRN medications. Failure to evaluate the patients' responses to PRN medications within the expected timeframe limited the nursing staffs' ability to assess whether the medications achieved the desired effect.

Findings include:

Review of the CAH's policy titled, "PRN Medication Reassessment" occurred on 04/23/19. This policy, dated June 2015, stated, ". . . The nurse who administers PRN (as needed) medications is also responsible for evaluating the effectiveness of the medication, and documenting this response. . . . Within one hour, the patient's physiological response is re-assessed. The time and effectiveness of the PRN medication is documented under the initial administration in the PRN MAR [medication administration record]. . . ."

The following records, reviewed April 22-23, 2019, showed CAH staff failed to assess the efficacy of PRN medications within the expected 60 minutes after administration:
- Patient #4 received Tramadol one time in April 2019 with no follow-up.
- Patient #5 received Morphine Sulfate 11 times in March 2019 with no follow-up assessment in the 60 minute time frame. The follow-up times ranged from 2 hours to 7 hours.
- Patient #8 received Ativan one time in February 2019 with no follow-up.
- Patient #9 received Dilaudid four times in December 2018 with no follow-up assessment in the 60 minute time frame. The follow-up times ranged from 2 hours to 3 1/2 hours.
- Patient #13 received Tramadol one time in June 2018 with no follow-up assessment in the 60 minute time frame. Facility staff followed up 6 hours later.
- Patient #17 received Hydrocodone one time in February 2019 with no follow-up.
- Patient #19 received Tylenol two times and Ibuprofen one time in January 2019, with no follow-up assessment in the 60 minute time frame. The follow-up times ranged from 2 hours to 5 hours.

During interview on the morning of 04/24/19, two administrative nurses (#2 and #3) stated they continue to complete quality assurance review on PRN medication follow-up every two weeks related to fluctuating percentage compliance rates. The Administrative nurse (#3) stated Epic (medical records system) does trigger staff for follow up on PRN pain medication, but staff are able to bypass the system.