HospitalInspections.org

Based on document review and staff interview, it was determined the facility failed to ensure facility policies are reviewed annually. Failure to review and update policies and procedures regularly has the potential to allow problems with delivery of health care services in the facility to go undetected and uncorrected.

Findings include:

1. Facility policy entitled "Policies-Board and Hospital", last reviewed 2/27/13 was reviewed on 1/13/15. It states in part, under the heading "Hospital Policies: such policies shall be reviewed annually and revised as necessary".

2. Facility policy and procedure manuals were reviewed on 1/13/15. The Quality Management and Dietary manuals were noted as last reviewed in 2011. The Medical Records manual was noted as last reviewed in 2012. The Emergency Department, Laboratory, Infection Control, Rehabilitation, Administrative and Nursing manuals were noted as last reviewed in 2013.

3. An interview was conducted with the Acute Care Nurse Manager on 1/13/15 at 11:40 a.m. at which time she agreed with the findings noted above.

Based on observations, document review and staff interviews it was determined the hospital failed to ensure all medications which have reached their expiration date are discarded and not used on patients. Additionally, the hospital failed to enforce policies that requires multidose medication vials to be dated when opened and discarded in twenty eight days. This deficient practice was found in two (2) of three (3) tubes of hydrocortisone gel and one (1) of one (1) dexamethasone vials. When expired medications are administered to patients it can result in patients receiving medications that are ineffective or potentially contaminated resulting in negative outcomes.

Findings include:

Review of policy entitled "Multiple dose containers of Drugs" revised 1/26/14 states in part the following: When multiple dose vials are used in a floor stock situation the following will apply: The person removing the first dose will initial the label and place an expiration date of 28 days on the label.

During a tour of the outpatient rehabilitation department on 1/13/14 at 8:45 a.m. two (2) tubes of hydrocortisone ultrasound gel (8.5 fluid ounce) were found to have expiration dates of 10/14/14. These topical medications are used for ultrasound phonophoresis. Additionally, a 30 milliliter (ml) vial of dexamethasone was found to be opened and partially filled with solution. The vial was not marked with the initials of who opened the medication or the expiration date.

The physical therapy assistant #1 (PTA 1) and Physical Therapist #1 (PT 1) on 1/13/15 at 8:55 a.m. agreed the tubes of gel were expired and the open vial of dexamethasone did not have the initials of who opened it or an expiration date. Both employees were asked after a medication vial is opened when does it expire and they both thought it was sixty (60) days after opening.

The Pharmacist was interviewed on 1/13/15 at 9:20 a.m. and she stated she does compound the hydrocortisone gel and it should be discarded after the expiration date. Additionally, she concurred that all medications vials are to the discarded twenty-eight (28) days after it is first opened.

Based on document review and staff interview it was determined the facility failed to provide evidence of a process for notifying the patient and/or support person of their visitation rights prior to providing services. This failure has the potential to deny all patients their rights to visitation by a support person of their choice.

Findings include:

1. The facility Admissions Packet, including "Patient Rights and Responsibilities", was reviewed on 1/13/15. The list of patient rights did not include any information regarding visitation rights and/or restrictions for patients in the facility.

2. An interview was conducted with the Acute Care Nurse Manager on 1/13/15 at 9:25 a.m. at which time the admissions material noted above was reviewed. The Acute Care Nurse Manager agreed the information provided to patient on admission failed to notify them of their rights regarding visitation.