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Based on observation, review of documentation and interviews with facility staff, the facility failed to properly store medications as controlled drugs requiring refrigeration were found stored unsecured in the pharmacy refrigerator. The facility policy regarding controlled substances did not specifically address controlled substances that require refrigeration. This potentially could have increased the likelihood of diversion of controlled drugs.

The findings were:

The facility policy entitled "Controlled Substances" # RX 4.07 reflected in part "IV. Storage of controlled substances. All controlled substances in Schedule II-V will be kept in the pharmacy PYXIS C-II SAFE until issued to a nursing unit."

From the Drug Enforcement Administration Practitioner's Manual, 2006 edition: "Practitioners are required to store stocks of Schedule II through V controlled substances in a securely locked, substantially constructed cabinet."

During a tour of the pharmacy on the afternoon of 8/17/15, Ativan 2 mg and 4 mg vials, a schedule IV controlled drug, was found stored in an unlocked drawer inside a pharmacy refrigerator. The drawer did have a keyed lock installed but it was unlocked. In an interview during the tour with the pharmacy director, staff # 26 on 8/17/15 at approximately 3:00 pm, staff #26 agreed that the Ativan vials were not secured.

Based on review of documentation and interviews with staff # 8, the facility failed to ensure that the post evaluations were completed by the CRNA after surgery. 2 of 8 medical records reviewed did not contain the anesthesia post evaluation per the CRNA.
Findings were:
2 of 8 medical records reviewed did contain a post anesthesia evaluation by the CRNA. Patient # 5 and patient #11 medical records did not contained the post- anesthesia/sedation evaluation.
In an interview with staff #8 on the afternoon of 8/18/15 at the facility staff # 8 agreed the post anesthesia forms had not been completed by the CRNA.

Based on observation, review of documentation and interviews with facility staff, the facility failed to ensure the safety of patients as there was no evidence that the temperature of the paraffin bath was being checked prior to use in patient care. This was not consistent with facility policy and potentially could have resulted in patient injury.

The findings were:

The facility policy entitled "Paraffin" reflected in part "2. Check the paraffin bath temperature with a candy or dairy thermometer. Do not apply paraffin if the temperature is above 130 degrees Fahrenheit. To lower the bath temperature, either unplug the line cord or remove the lid."

During a tour of the rehabilitation department on the afternoon of 8/17/15, a paraffin bath filled with hot molten paraffin was observed. In an interview during the tour on 8/17/15 at approximately 4:50 pm, the PTA, staff #21 and Rehab Aide, Staff #22 were asked if there was a temperature log or any record that the temperature of the paraffin was checked. Staff #21 and 22 stated that the temperature of the paraffin was not checked and there were no records of it being checked.

Based on observation and review of documentation the facility failed to provide appropriate activities for the swing bed patients as the facility did not have an activity director.
Findings were:
Review of facility policy Activities Program stated the swing bed program will provide activities appropriate to the needs and interests of each patient and in accordance with the patients abilities. The activities program will encourage self-care, resumption of normal activities and maintenance of an optimal level of psychosocial functioning.
In an interview at facility on the afternoon of 8/18/15 staff # 7 agreed with the findings that the facility did not have a swing bed activities director.