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Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure a Physician's order for restraints was obtained for one (1) of thirty-one (31) sampled patients (Patient #8). Patient #8 was restrained on 01/06/13 without an order.

The findings include:

Review of the facility's policy titled "Restraints/Seclusion", with a revised date of October 2012, revealed the use of restraint or seclusion must be in accordance with the order of a Physician or other LIP who is responsible for the care of the patient. For non-violent restraints the initial order must not exceed twenty-four (24) hours and ongoing orders must not exceed one (1) calendar day.

Review of Patient #8 medical record revealed an admission date of 01/05/13 with diagnoses which included Acute Respiratory Failure and Respiratory Arrest. Review of the Physician's order, dated 01/05/13, revealed the patient required soft restraint for the right and left wrist due to interference with medical treatment, duration for the restraints was twenty-four (24) hours. Continued review of the medical record revealed no subsequent Physician's order for the restraints for 01/06/13, even though the facility continued to utilize soft wrist restraints for Patient #8 on 01/06/13.

Interview with Registered Nurse (RN) #10, on 01/11/13 at 2:50 PM, revealed the restraints had been initiated in the Emergency Department on 01/05/13 prior to getting to the Intensive Care Unit (ICU) because Patient #8 was pulling at his/her tubes and lines. RN #10 stated she may have forgotten to put the order in the system.

Interview with the Quality Improvement/Joint Commission Coordinator, on 01/11/13 at 3:00 PM, revealed there was no re-order for the restraint for 01/06/13. She verified hospital policy mandated a new order be obtained every day.

Based on observation, interview and review of facility's policy, "Outdated Drug Control", review date 03/12, it was determined the facility failed to have an inventory management system that ensured outdated medications were not available for patient use. Nineteen (19) vials of an outdated Injectable and two (2) syringes without a date in which they were drawn up or a date the medication expired, were on the shelf with other medications to be administered.

The findings include:

Review of facility's policy, "Outdated Drug Control", review date 03/12, revealed extreme care must be exercised that no expired medication are dispensed for patient use or allowed to remain in the dispensing area of the pharmacy or patient areas. The pharmacy personnel will constantly check all medication physically for dated items and remove all outdated packages from the shelves. All expired drugs that are not scheduled will be placed in the outdated drug section of the pharmacy storeroom.

Observation during tour of the Pharmacy, on 01/10/13 at 9:00 AM, revealed a carton with nineteen (19) vials of Ex Pyridoxine (Vitamin B6) Injectable, one hundred milligrams per milliliter, with an expiration date of 12/12. Also two syringes with Brompheniramin/phylephrin (antihistamine and decongestant combination) for a patient were noted with no experation date or date in which the medication was drawn up in the syringes.

Interview with the Director of Pharmacy, on 01/10/13 at 10:00 AM, revealed the Pharmacy staff checked visually for outdated drugs, such as when the staff was going to get a drug. He stated the goal was to try to do a complete turnaround every three (3) months depending on the workload and volume. He stated the expired medication as well as the syringes without the date drawn up or expiration should not have been on the shelf.

Interview with Certified Pharmacy Technician (CPT) #1, on 01/11/13 at 2:40 PM, revealed two (2) or three (3) times a week the pharmacy staff inspected each crash cart for expired medications. She stated the program the pharmacy used could bring up all medications that were going to be outdated within three (3) to four (4) weeks. She stated the by mouth and injectable medications were pulled as they came up on the screen, but the narcotics were kept until the last day. The CPT stated once a week, she would pick a medication and go through all station and visually check for the expiration date.