HospitalInspections.org

Based upon review of personnel files, and interviews with staff the facility failed to provide services in a safe setting.

Findings:

a. Reviewed 17 Staff personnel files, found 4 staff members who had positive urine drug screen results since being employed at the facility, 3 of those files contained documentation required per facility policy for staff member to return to work, 1 file did not contain the proof required per facility policy for staff member to return to work.

b. Interviewed Director of Human Resources on 21 November, 2011 in the administration conference room, she stated that by facility policy all staff members that have positive urnie drug screen results are required to bring in proof of any medication that is prescribed or over the counter that they took, but she agreed that one (1) staff member file did not contain proof required and three (3) other staff member files did contain the required documentation. The Director of Human resources confirmed that staff member was allowed to return to work but could not provide evidence that staff complied with requirement.

Upon facility tour, interview with staff and review of policies and procedures, the facility failed to ensure that controlled substances are secured and locked as required.

Findigns:

a. Upon facility tour of the emergency room, found that controlled substances are being stored in small metal cabinet with two drawers. The cabinet key was found in an unattended desk drawer by the nurses station.

b. Interviewed staff nurse who stated that key is supposed to be with staff nurse but sometimes they just put it in the drawer so that all staff can find it easily. She confirmed that the key was not secured and that desk where key is kept is sometimes unattended.

c. Reviewed facility policy titled "Distribution and administration of controlled subtances" Procedure 2.4.12 states that Keys to the narcotic drawer are kept by each nurse dispensing medication." Staff nurse agreed that the key is not being kept by each nurse and that sometimes they put it in the drawer. She was unable to provide evidence with compliance to this policy.