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Based on observation and interview, the facility failed to ensure outdated medications were not available for patient use on two (Medical/Surgical Unit, Intensive Care Unit) of six (Surgery, Preoperative/Postoperative Unit, Medical/Surgical Unit, Intensive Care Unit, Behavioral Health Unit, Emergency Department) nursing areas. The potential existed for outdated medications to be administered to the average daily Medical/Surgical patient census of 7.8 and the average daily Intensive Care Unit patient census of .1. Findings follow:

A. A tour of the Medical/Surgical Nursing Unit was conducted on 03/17/11 at 1015. Sixteen multiple dose vials of Bacteriostatic 0.9% Sodium Chloride were observed expired as of 02/01/11.
B. An interview was conducted with the Medical/Surgical Nursing Supervisor at 1030 on 03/17/11. The Medical/Surgical Nursing Supervisor verified the vials of Bacteriostatic 0.9% Sodium Chloride were outdated and available for patient use.
C. A tour of the Intensive Care Unit was conducted on 03/17/11 at 1040. The following medications were observed to be expired:
1) One naloxone 0.4 milligrams (mg)/milliliter (ml) expired 02/01/11;
2) One Heparin 10,000 units (u)/10 ml expired 11/10;
3) One Dexamethasone Sodium Phosphate 20mg/5ml expired 02/11;
4) One Levophed 4mg/4ml expired 03/01/11; and
5) One vial of Lidocaine 10mg/ml expired 01/01/11.
D. An interview was conducted with the Intensive Care Unit Supervisor on 03/17/11 at 1055. The Intensive Care Unit Supervisor verified the medications were expired and available for patient use.


Based on observation, manufacturer label review, Pharmacy Policy and Procedure Manual review, and interview, the facility failed to ensure Succinylcholine, Atracurium and Rocuronium Bromide were stored according to manufacturer guidelines and hospital policy on one of one anesthesia cart maintained in Surgery. The facility also failed to ensure those medications were not available for patient use. The potential existed for the medications to have a decrease in potency and be administered to an average weekly census of 14 surgery patients if ordered. Findings follow:

A. A tour of Surgery was conducted on 03/16/11 at 1320. Two vials of Succinylcholine 200 milligrams (mg)/10 milliliters (ml), one vial of Atracurium 50mg/5ml, and one vial of Rocuronium Bromide 100mg/10ml were observed on the one anesthesia cart maintained in Surgery stored at room temperature with no evidence when the medications were removed from refrigeration.
B. Manufacturer label review of the three medications was conducted on 03/16/11 at 1330. The review revealed the three medications could only be stored out of refrigeration and at room temperature for specified periods of time. Multiple dose vials of Succinylcholine and Atracurium could be stored at room temperature for 14 days and Rocuronium Bromide for 60 days unopened and 30 days opened.
C. An interview was conducted with the Operating Room Supervisor on 03/16/11 at 1340. The interview revealed there was no evidence to indicate when the three medications were removed from refrigeration nor length of time stored at room temperature, and the medications were available for patient use.
D. On 03/18/11 at 0830, Policy 09-01 in the Pharmacy Policy and Procedure Manual was reviewed. The policy revealed medications would be stored according to manufacturer guidelines. A second policy "Storage of Neuromuscular Blocking Agents" which referred to the the three medications was reviewed. It reflected that Succinlycholine, Atracurium and Rocuronium Bromide would be dated with an expiration date when removed from refrigeration and stored at room temperature. The expiration date was 14 days after removing Succinylcholine and Atracurium from refrigeration and 60 days for Rocuronium Bromide if unopened and 30 days if opened.

Based on inspection documentation review and interview it was determined the facility failed to meet Life Safety Code requirements related to damper inspection. Failure to inspect fire dampers prevents the facility from ensuring the reliability of the dampers to close in the event of a fire or smoke event. The failed practice had the potential to affect all patients, staff, and visitors. The facility had a census of 15 patients on 03/16/11.

Based on testing documentation review and interview it was determined the facility did not meet Life Safety Code requirements related to monthly and annual testing of Emergency Battery Powered Light fixtures as required by NFPA 101 Section 7.9.3. Failure to perform the required testing of the emergency light fixtures prevents the facility from ensuring the reliability of the emergency lights to illuminate the area in the event of a loss of normal power. The failed practice had the potential to affect all patients, staff, and visitors. The facility had a census of 15 patients on 03/16/11.

Based on inspection report documentation review, observation, and interview it was determined the facility did not meet Life Safety Code requirements related to complete hood fire suppression system coverage of kitchen equipment. Incomplete coverage of the fire suppression system has the potential to prevent the system from fully and completely extinguishing a fire under the kitchen hood, which could spread fire and smoke throughout the facility and damage cooking equipment required to prepare meals for patients. The failed practice had the potential to affect all patients, visitors, and kitchen staff. The facility had a census of 15 patients on 03/16/11

Based on clinical record review, policy and procedure review and interview, the facility failed to ensure policies and procedures were documented and implemented for the use of alcohol containing surgical skin preparations that included fire safety measures for three of three (#28-#30) operative patients on which an alcohol containing surgical skin preparation was used. The failed practice placed the patients at increased risk of injury from fire and had the potential to affect all patients on which an alcohol containing surgical skin preparations was used. See A951 for details.

Based on clinical record review, policy and procedure review and interview, the facility failed to ensure policies and procedures were documented and implemented for the use of alcohol containing surgical skin preparations that included fire safety measures for three of three (#28-#30) operative patients on which an alcohol containing surgical skin preparation was used. The failed practice placed the patients at increased risk of injury from fire and had the potential to affect all patients on which an alcohol containing surgical skin preparations were used. The findings follow:

A. Review of Operative Reports for Patients #28-#30 revealed the Patients' skin was prepped with DuraPrep Surgical Solution; there was no evidence the skin was allowed time to dry before draping of the patient; and a cautery device was used during each procedure.
B. Review of the exterior packaging of the DuraPrep Surgical Solution revealed the product contained Isopropyl Alcohol, 74%. Warnings listed on the exterior packaging revealed, "Do not drape or use ignition source (for example, cautery, laser) until solution is completely dry (minimum of three minutes on hairless skin; up to one hour in hair)."
C. Review of the Surgery Department Safety policy provided by the Operating Room Supervisor on 03/17/11 at 0855 revealed, "Flammable germicides or any fat solvent preparations shall not be applied for preoperative preparations of the field."
D. Review of the Surgical Services Policy and Procedure Manual on 03/17/11 revealed there was no evidence of policies and procedures, including implementation of fire safety measures, in the use of the DuraPrep Surgical Solution or other alcohol containing surgical skin preparations.
E. The findings were confirmed in an interview with the Operating Room Supervisor on 03/17/11 at 0855.

Based on review of policies and procedures for the Swing-Bed Program, closed record review and interview, it was determined the facility failed to identify the activity needs for one of one patient and failed to assure patient activities were directed by a qualified therapeutic recreation specialist, a qualified activities professional, a qualified occupational therapist, occupational therapy assistant, or by an individual who had completed a State approved training course. The potential existed for all patients admitted to the Swing-Bed Program to have unmet activity needs. The findings are:

A. Review of closed clinical record for Patient #1 revealed the patient was admitted to the Swing-Bed on 02/14/11 and discharged on 02/18/11. The clinical record did not include documentation of a comprehensive activities assessment.

B. Swingbed policies and procedures were reviewed on 03/18/11. Policy #II.8 "Activity Assessment Swing-Bed Program" stated "A written activity assessment will be done on each patient admitted to Swing Bed. Information for the assessment is obtained through an interview with the patient and/or family member and is documented by the Occupational Therapist. Activity goals, both individual and group will be set according to the patient's physical, mental and emotional status will be read, assessed, and signed by the attending physician." Policy #I.2, "Patient Activities for Swing-Bed Program" revealed "(Facility name) provides for an activities program appropriate to the needs and interests of each patient to encourage self-care, to resume activities of daily living and to maintain a functional level as independent as possible. Responsibility of patient activities; (facility named) provides an occupational therapist who is available through the Rehab Service Department."

C. In an interview with the Swingbed Coordinator on 03/18/11 at 1150, she confirmed the lack of activities assessment for Patient #1 and stated the facility did not have an Occupational Therapist for the Swing-Bed Program, "We don't have an Occupational Therapist, we only have physical therapy."