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Based on interview and record review, the facility failed to provide compounding medication services by the pharmacy after 5 pm daily (refer to A-491 and A-501). This forced nursing staff in the emergency department to prepare medications for patients without the required biological safety cabinet. This method exposed patients to unnecessary contamination risks and the resulting potential harm.

Based on interview and record review, the facility failed to provide compounding medication services by the pharmacy after 5 pm daily. This forced nursing staff in the emergency department to prepare medications for patients without the required biological safety cabinet. This method exposed patients to unnecessary contamination risks and the resulting potential harm. The findings are:

A. On 01/19/16, at 11:15 am, the facility Pharmacist #1 stated the following during interview: "During the pharmacy hours, the pharmacy mixes these medications in a biological safety cabinet. However, at night, the pharmacist does not come into the hospital to compound these products, but they are instead compounded by the emergency room nurse. The nursing staff in the emergency room are mixing medication after pharmacy hours for non-urgent situations." Pharmacist #1 confirmed that patients were not always receiving medication that has been prepared in sterile conditions for non-urgent situations.

B. Record review of the facility's policy entitled "Sterile Admixtures in Pharmacy" (policy RX.PDF.028) revealed the following protocol: "All sterile admixtures shall be prepared by Pharmacy Services Department personnel, except in emergencies or when not feasible. Solutions shall be prepared in a laminar air-flow workbench, glove boxes, or biological safety cabinet. Aseptic technique shall be employed when a a sterile admixture is prepared."

Based on interview and record review, the facility failed to provide compounding medication services by the pharmacy after 5 pm daily. This forced nursing staff in the emergency department to prepare medications for patients without the required biological safety cabinet. This method exposed patients to unnecessary contamination risks and the resulting potential harm. The findings are:

A. On 01/19/16, at 11:15 am, the facility Pharmacist #1 stated the followingn during interview: "During the pharmacy hours, the pharmacy mixes these medications in a biological safety cabinet. However, at night, the pharmacist does not come into the hospital to compound these products, but they are instead compounded by the emergency room nurse. The nursing staff in the emergency room are mixing medication after pharmacy hours for non-urgent situations." Pharmacist #1 confirmed that patients were not always receiving medication that has been prepared in sterile conditions for non-urgent situations.

B. Record review of the facility's policy entitled "Sterile Admixtures in Pharmacy" (policy RX.PDF.028) revealed the following protocol: "All sterile admixtures shall be prepared by Pharmacy Services Department personnel, except in emergencies or when not feasible. Solutions shall be prepared in a laminar air-flow workbench, glove boxes, or biological safety cabinet. Aseptic technique shall be employed when a a sterile admixture is prepared."

Based on record review and interviews, the facility failed to appoint a qualified physician to direct the Anesthesia Services provided at the hospital. The facility also failed to define the qualifications for the Director of Anesthesia as well as the responsibilities for the position in its policies and procedures. The findings are:

A. On 01/19/16 at 1:30 pm during interview, with the senior leadership (OR Manager, Hospital Administrator, Accreditation/Regulatory Program Director), the question was raised if there was an appointed Director of Anesthesia Services. The staff members were asked to provide the survey team with the position description that contained the qualification for this position as well as the responsibilities. The staff responded that no qualified physician currently filled that position. The leadership confirmed that Anesthesia Services are provided by the hospital.

B. Record review indicated no policies or procedures related to Anesthesia Services. No policies or procedures related to anesthesia practice -- including pre-anesthesia assessments, intraoperative (during an operation) management and monitoring, and post-anesthesia care -- were in evidence.

C. Record review of "Exhibit A- Medical Director Perioperative Services," a facility document which defined the responsibilities for this position, revealed no content related to anesthesia standards and processes. No other documents pertaining to Anesthesia Services or the position of Director of Anesthesia Services were provided by the facility.