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Based on review of documentation, it was determined that the facility failed to ensure that policies and procedures were reviewed routinely.

Findings were:

Policy and procedure manuals for the following departments had no documentation demonstrating recent review:
? Health Information Management: last documented review-10/17/08
? Cardiopulmonary: last documented review-10/25/06
? Emergency Room: last documented review-1997
? Obstetrics: last documented review-1995
? Admissions: last documented review-10/23/08
? HIPPA (Health Insurance Portability and Accountability Act): last documented review-4/04/03
? Operating Room: last documented review-7/16/87

In an interview with the Director of Nurses on 5/26/10, it was confirmed that the above departments were lacking evidence of a recent review of policy and procedures.

Based on observation, it was determined that the facility failed to ensure that all controlled drugs were kept in a secure location.

Findings were:

Hospital policy entitled "Medication Management-Controlled Substances" stated, "All controlled drugs will be stored in a locked, secured area to prevent diversion."

Tour of the pharmacy on 5/26/10 revealed 55 2mg/1ml vials of Ativan stored in the medication refrigerator. This refrigerator was unlocked and the Ativan was stored in an open bin inside the refrigerator.

In an interview with the Pharmacy Technician on 5/26/10, it was confirmed that controlled medications were stored in an unsecured location.

Based on observation, it was determined that the facility failed to ensure that supplies were maintained at an acceptable level of safety and quality.

Findings were:

1. Facility policy entitled "Refrigerator, Freezer and Warmer Inspection Records" stated "A record of refrigerator, freezer and warmer inspections shall be maintained. This record shall verify that all medications requiring refrigeration, freezer or warmer temperatures are within the acceptable range. Refrigerators and freezers used for storage of vaccines should have temperatures recorded at least twice a day."

The pharmacy refrigerator log had not been monitored from 5/13/10 to the date of survey, 5/26/10. From 3/01/10 to 5/13/10 the refrigerator had only been checked once a day rather than twice a day as required by the facilities policy.

2. Facility policy entitled "Event-Related Shelf Life-Sterile Storage" stated "Expiration dates may be used if medication or materials that deteriorate with time are contained in the package. Package will be dated with the manufacturer's recommendation when this occurs ....Surgical Services staff is responsible for checking integrity of packaging and storage methodology on a daily, weekly and monthly basis.

Tour of Operating Room # 1 on 5/26/10 revealed the following expired supplies:
? 14 of 14 Penrose Drains with an expiration date of 7/07
? 5 of 5 Coverlet Adhesive Surgical Dressings with an expiration date of 10/05
? 18 of 18 T-Tubes with an expiration date of 8/04

In an interview with the Trauma Coordinator, RN on 5/26/10, the above expired supplies were confirmed. In an interview on that same day with the Pharmacist, it was acknowledged that the refrigerator in the pharmacy should have temperature checks done twice daily.

Based on observation, it was determined that the facility failed to follow its own policy for routinely checking crash carts.

Findings were:

Facility policy entitled "Emergency Crash Cart Security and Accountability" stated, "The nursing personnel shall visually inspect the numbered break-away lock located on the crash cart at each change of shift, documenting that the cart is properly locked with all of the appropriate contents present and intact."

Review of a document entitled "Crash Cart Check List" for ER beds A & B, and C & D on 5/26/10 revealed infrequently documented daily checks for the past 6 months. No more than 7 daily checks per month had been documented during the 6 month period.

In an interview with the House Supervisor on 5/26/10, it was confirmed that crash cart checks were not documented daily.