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Based on observation, staff interview, and policy review, the facility failed to ensure policies for drug storage and handling expired drugs and intravenous (IV) fluids were followed on two (2) of two (2) days of survey.


Findings Include:

Observation of the Emergency Room (ER) crash cart on 02/27/17 at 2:45 p.m. revealed that Drawer 5 contained one (1) Tuberculin syringe and one (1) Melcor CO2 detector, both expired 09-16. This was verified by an ER Registered Nurse at 3:20 p.m.


Observation of the crash cart on the Geri-psych floor at 3:30 p.m. on 02/27/17 revealed two (2) defibrillator pads which had an expiration date of 04-16. This was verified at that time by the Acting Director of Nursing.


Observations on the medical unit, made with the Pharmacist Director on 02/28/17 beginning at 12:30 p.m., revealed the following expired supplies, drugs, and intravenous (IV) solutions:
Adult Crash Cart:
One (1) 22 gauge one (1) inch Protect IV Needle expired 9/16.
One (1) Hypodermic needle-Pro Tuberculosis (TB) syringe expired 9/16.
12 100 milliliter (ml) bags of 5% Dextrose IV Solution expired 10/16.
One (1) 100 ml bag of Sodium Chloride 0.9% IV Solution expired 01/17.
One (1) 100 ml bag of Sodium Chloride 0.9% IV Solution expired 3/16.
One (1) 500 ml bag of 0.45% Sodium Chloride IV Solution expired 9/16.
One (1) 200 ml bag of Sodium Chloride IV Solution expired 9/16.
Three (3) 500 ml bags of 0.2% Sodium Chloride IV Solution expired 9/16.
Six (6) 100 ml bags of 5% Dextrose IV Solution expired 9/16.

Pediatric Crash Cart:
One (1) Pediatric Emergency System expired 7/16.
One (1) Pediatric Emergency System expired 6/16.
Four (4) 100 ml bags of 0.9% Sodium Chloride IV Solution expired 11/16.
Seven (7) 250 ml bags of 0.9 % Sodium Chloride IV Solution expired 7/16.
Three (3) 250 bags of 0.9 % Sodium Chloride IV Solution expired 9/16.
Seven (7) 200 ml bags of 5% Dextrose IV Solution expired 9/16.
Three (3) 250 ml bags of 5% Dextrose and 0.2 % Sodium Chloride IV Solution expired 10/16.
Four (4) 500 ml bags of 5% Dextrose and 0.45% Sodium Chloride IV Solution expired 6/16.
Four (4) 100 ml bags of Sodium Chloride 0.9% IV Solution expired 1/16.
Four (4) 250 ml bags of Sodium Chloride IV Solution expired 7/16.
Six (6) 500 ml bags of Dextrose and 0.2% Sodium Chloride IV Solution expired 4/16.
Seven (7) 500 ml bags of 0.45% Sodium Chloride IV Solution expired 6/16.
Three (3) 500 ml bags of 5% Dextrose and 0.45 % Sodium Chloride IV Solution expired 6/16.
Six (6) 250 ml bags of Dextrose 5% IV Solution expired 10/16.

Observations made of the medication refrigerator with the Pharmacist Director on the same date and time revealed:
One (1) opened vial of Novolog Insulin; one opened vial of Humulin 70/30 Insulin; and one opened vial of Novolog Insulin all had no opened date and no beyond use date documented.
The freezer section of the refrigerator was incased in ice.
The refrigerator thermometer revealed the temperature was 32 degrees Fahrenheit (F) on 02/28/17 at 2:00 p.m. This finding was discussed with the Pharmacist Director on 03/01/17 at 2:00 p.m. and was rechecked at that time. It remained 32 degrees F. The Pharmacy Department Medication Storage Area Inspection forms indicated thermometer readings of 36-46 degrees F were the acceptable thermometer reading temperatures.


Review of the facility's "Pharmacy's Medication Management-Storage Policy - Subject: Inspections Of Medication Areas" (approved 10/2013) revealed: "Policy: The Director of Pharmacy or qualified designee shall conduct routine (preferably monthly) inspections of all medications areas (e.g., nursing-care units, emergency medication containers, and other areas where medications are dispensed, administered or stored.) Areas to Inspect: Inspections shall include the main pharmacy, all nursing care units, medication storage units, emergency boxes and emergency carts, and all other areas of the facility where medications are dispensed, administered or stored... Outdated or otherwise unusable medications are identified, removed from stock, and stored to prevent their distribution and administration... A record of refrigerator, freezer and warmer inspections shall be maintained. This record shall verify that all medications requiring refrigeration, freezing or warming are properly stored and that refrigerator, freezer or warmer temperatures are within the acceptable range."


Review of the facility's "Infection Control Policy - Multiple-Dose Sterile Medications" (approval date 10/2013) revealed: "...Multiple-dose vials are clearly marked by the manufacturer. The manufacturer's expiration date is applicable if the vial is unopened and stored per recommendations. USP and APIC recommend that opened or punctured multiple-dose vials be used for no more than twenty-eight (28) days. Once the vial is opened, a beyond-use date must be applied to it if it will be reused. Note: marking the date opened is not sufficient to comply with this policy. The healthcare professional first puncturing the vial must place the beyond-use date on the vial unless the pharmacy has already done so. Multiple-dose vials may be used for up to 28 days after the initial entry when stored as required in the package labeling, unless the manufacturer recommends a shorter time."


21914

Based on record review, policy review and staff interview, the facility failed to ensure:
1. all medical records are accurate and completed promptly in accordance with facility policy; and
2. facility policy is followed regarding physican notification of delinquency.


Findings include:


Cross Refer to C302 for the facility's failure to ensure Patient #1, #3, #4, #5, #6, #7 and #10 had a discharge summary on their chart, failure to ensure Patient #2, #5, #6, #9 and #10 had a History and Physical on their chart, and failure to ensure a physician's order was noted by a nurse on Patient #8's chart.

Cross Refer to C304 for the facility's failure to ensure Patient #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10 had a History and Physicial and/or a discharge summary on their chart.

Cross Refer to C305 for the facility's failure to ensure Patient #2, #5, #6, #9 and #10 had a History and Physical on their chart.

Cross Refer to C306 for the facility's failure to ensure Patient #1, #3, #5, #6, #7 and #10 had a discharge summary on their chart.


Review of the facility's "Delinquent Medical Records" policy (effective 04/23/2016) revealed: "Policy: ... The Health Information Management Department shall notify a practitioner of suspension when he/she has delinquent medical records. Procedure: Physicians will be notified on a biweekly basis of their number of incomplete medical records through a letter until medical records are complete or the physician is on suspension... Should the medical record(s) remain incomplete on the 15th day after patient discharge, the Health Information Management Department will notify the physician...that his/her admitting, consultive and surgical privileges have been suspended until his/her medical records have been completed... Any patient remaining in the hospital more than 24 hours shall require a dictated discharge summary..."


On 02/01/17 at 11:50 a.m. an interview with the Director of Health Information Management Department revealed, "Physician's are notified of delinquent records at least once a month, but they are not suspended. The delinquent report is taken to medical staff meeting if not taken care of....There are 10 delinquent charts greater than 30 days that are missings H&Ps, discharge summaries and one that didn't have an order noted off."

Based on medical record review, document review, and staff interview, the facility failed to maintain a clinical record that was legible, complete, accurately documented, readily accessible, and systematically organized for 10 out of 10 delinquent medical records reviewed. Patient #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10.


Findings Include:


Review of the facility's "Deficiency Chart 30 Days or Greater" document, submitted by the Director of Health Information Management (DHIM), revealed there were 10 incomplete medical records with discharge dates ranging from 12/06/16 through 12/23/16.


Review of the incomplete records revealed: Patient #1, #3, #4, #5, #6, #7 and #10 did not have a discharge summary on the chart; Patient #2,#5, #6, #9 and #10 did not have a history and physical exam on the chart; and Patient #8 had a physician's order for lab work, dated 12/6/16, that had not been noted by a nurse.


During an interview on 03/01/17 at 11:50 a.m. the DHIM confirmed these findings.

Based on medical record review and staff interview, the facility failed to ensure nine (9) of 10 delinquent records reviewed had a history and physical and/or a discharge summary. Patient #1, #2, #3, #4, #5, #6, #7, #9 and #10.


Findings Include:


Review of the facility's "Deficiency Chart 30 Days or Greater" document, submitted by the Director of Health Information Management (DHIM), revealed there were 10 incomplete medical records with discharge dates ranging from 12/06/16 through 12/23/16. Review of the incomplete records revealed: Patient #1, #3, #4, #5, #6, #7 and #10 did not have a discharge summary on the chart, and Patient #2,#5, #6, #9 and #10 did not have a history and physical exam on the chart.


During an interview on 03/01/17 at 11:50 a.m. the Director of Health Information Management confirmed these findings.

Based on medical record review and staff interview, the facility failed to maintain complete clinical records which included History and Physicals (H&Ps) for five (5) of 10 delinquent medical records reviewed, Patient #2, #5, #6, #9 and #10.


Findings Include:


Review of the facility's "Deficiency Chart 30 Days or Greater" document, submitted by the Director of Health Information Management (DHIM), revealed there were 10 incomplete medical records with discharge dates ranging from 12/06/16 through 12/23/16.


Review of the 10 records revealed Patient #2, #5, #6, #9 and #10 did not have a H&P on their chart.


During an interview on 03/01/17 at 11:50 a.m. the Director of Health Information Management confirmed these findings.

Based on medical record review and staff interview, the facility failed to ensure seven (7) of 10 delinquent medical records reviewed contained discharge summaries, Patient #1, #3, #4, #5, #6, #7 and #10.

Findings Include:


Review of the facility's "Deficiency Chart 30 Days or Greater" document, submitted by the Director of Health Information Management (DHIM) revealed there were 10 incomplete medical records, with discharge dates ranging from 12/06/16 through 12/23/16. Review of the incomplete records revealed that Patient #1, #3, #4, #5, #6, #7 and #10 did not contain a discharge summary.


During an interview on 03/01/17 at 11:50 a.m. the DHIM confirmed these findings.

Based on observation and staff interview, the facility failed to provide an activity calendar for swing bed patients.


Findings Include:


Observation on 02/28/17 at 11:55 a.m. revealed no posted activity calendar in the facility. An interview with the Activity Director on 02/28/17 at 3:05 p.m. confirmed there was no posted activity calendar.