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FREEDOM BEHAVIORAL HOSPITAL OF MONROE
SECURE STORAGE
Tag No.: A0502
Based on observation and interview, the hospital failed to ensure all drugs and biologicals were kept in a secure area. This deficient practice is evidenced by 1 (SF11US) of 1 unlicensed personnel having access to the medication room on the nursing unit.
Findings:
In an observation on 10/13/2020 at 4:30 p.m., when asked for entrance into the nursing station medication room, SF6RN charge nurse did not know the access code to allow entry. SF11US said she would let the surveyors and SF1CEO in and typed in the access code and unlocked the door to the medication room. Further observation revealed an unlocked medication cart with all of the current patients' medications except narcotics and unlocked cabinets with stock medications.
In an interview on 10/13/2020 at 4:32 p.m., SF1CEO verified the unit secretary should not have access to the medication room.
DIRECTOR OF DIETARY SERVICES
Tag No.: A0620
Based on record reviews and interviews, the hospital failed to ensure a full-time employee, delegated by the governing body and medical staff, served as director of the food and dietetic services, was responsible for the daily management of the dietary services, and was qualified by experience or training.
Findings
Review of the list of employees presented by SF1CEO revealed no documented evidence that a Dietary Manager was included in the list.
In an interview on 10/13/2020 at 11:20 a.m. S1F2DON indicated the hospital did not have a full-time employee who was responsible for the daily management of the dietary services. She further indicated the Registered Dietitian is contracted and does not work for the hospital full-time. She reported that the previous Dietary Manager transferred recently to their offsite campus in another city, but does not come to this campus anymore. She reported that the charge RN on each shift was responsible for overseeing dietary services provided on site, not a designated person.
In an interview 10/13/2020 at 11:30 a.m. SF1CEO confirmed the hospital did not currently have a dietary manager delegated by the governing body and medical staff for this campus and qualified by experience or training.