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Based on observation and interview, the hospital failed to ensure all medical records were properly stored in secure locations where they were protected from water damage in the event that the sprinkler system was activated.
Findings:

Observation on 07/19/17 at 11:00 a.m. of the medical records office revealed a desk that had approximately 200 closed paper medical records on top of it. Further observations revealed that the room contained sprinklers in the ceiling. At that time, interview with S3Medical Records Clerk revealed that the scanner was broken and all of the medical records on the desk were in need of scanning. She further stated that the records went back three months. When asked if the paper medical records would be protected from destruction or damage if the sprinkler system was activated, she stated no.

On 07/19/17 at 11:30 a.m., interview with S1DON confirmed that the above paper medical records were not protected from destruction or damage should the sprinkler system be activated.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice, consistent with state law. This deficient practice was evidenced by failing to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist, before the first dose was dispensed, for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications.
Findings:

Review of the Louisiana Administrative Code, Professional and Occupational Standards,
Title 46: LIII, Pharmacist, Chapter 15, Hospital Pharmacy, §1511. Revealed in part:
Prescription Drug Orders
A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial
dose of medication, except in cases of emergency.

On 07/17/17 at 11:00 a.m., interview with S2Pharmacist revealed that the hospital pharmacy is open Monday-Friday 8:00 a.m.-5:30 p.m and the hours vary on weekends. S2Pharmacist stated that if a new medication is ordered after pharmacy hours, the nurses obtain the medication from the "night cabinet" and administer it to the patient. He stated that a first dose review is not always conducted prior to the first dose of medication being administered to the patients after pharmacy hours. He further stated that it was his understanding that the nurses could administer the first dose of a medication, but a pharmacy review must be conducted prior to the next dose being administered.

On 07/18/17 at 2:30 p.m., interview with S1DON revealed that in the past, when a patient received a new medication order after pharmacy hours, the nurses would scan the information thru the hospital's computer system to S2Pharmacist for him to review from home. She further stated that due to issues with the computer system and the hospital only having one pharmacist, the nurses are no longer doing that procedure. S1DON revealed that it was her understanding that the nurses were allowed to give only one dose of a medication prior to the pharmacy review.

On 07/18/17 at 3:00 p.m., interview with S2Pharmacist revealed that there was no policy and procedure developed to address the requirement of the pharmacist to review all medication orders (except in emergency situations), before the first dose was dispensed, for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications.

Based on observations and interviews, the hospital failed to ensure outdated drugs were not available for use. This was evidenced by having expired medications in the "night cabinet", narcotic cabinet and in 2 of 2 crash carts in the hospital.
Findings:

On 07/17/17 at 10:00 a.m., observations in the medication room revealed the "night cabinet" contained the following expired medications:
Fluconazole 200mg/100mL injections (4), expired May 2017
Guaifenesin/Dextromethorphan 10mg/10mL, 5 mL containers (5), expired June 2017
Metoclopramide 10mg/mL vials (17), expired March 2017
Magnesium sulfate vials (8), expired March 2017
Folic acid tablet (1), expired March 2017

On 07/17/17 at 2:00 p.m. observation of the crash cart that was stored by the nurses station revealed the following expired medications:
Calcium Gluconate 100mg/mL, 10mL vial (10), expired May 2017
Epinephrine 1:1000, 30mL vial, expired June 2017
Epinephrine 1:1000, 1mL vial, expired 07/01/17
Heparin 5000 units/mL, 1mL vial, expired November 2016

On 07/17/17 at 2:20 p.m., observation of the narcotic cabinet revealed the following expired medications:
Donnatal Elixir (2 doses), expired 06/30/17
Diazepam 2mg tablets (13), expired 04/30/17
Tranxene 7.5mg tablets (22), expired 06/16/17
Fioricet 50/325/40mg tablets (4), expired 03/31/17
Ambien 12.5mg tablets (23), expired May 2017

Observations in the Emergency Department on 07/17/17 at 2:30 p.m. revealed the Crash Cart contained eight 10cc vials of Calcium Gluconate that had expired in May 2017.

On 07/18/17 at 3:15 p.m., S1DON confirmed the above medications were expired and were available for use on the patients in the hospital.