HospitalInspections.org

The Hospital identified a census of 5 patients. Based on observation, document review, and staff interview the hospital failed to safeguard patient drugs and biologicals for 2 of 5 patients (patient #s 47, #33).

Findings include:

Hospital Policy titled "MEDICATION ADMINISTRATION POLICY" #7.2.3, reviewed on 10/31/12 at 2:00pm stated "...2....d. When no one is in the medication room, it will be locked" "3. ADMINISTERING MEDICATIONS section e. directed staff to sign out at the time of obtaining and "They will then be administered by the medication nurse to the appropriate patient..."

Observations on 10/30/12 at 7:45am in a patient hallway (or define where) revealed of an unlocked and unattended Omnicell Mobile medication cart (a locked computerized medication delivery cart) with a 1 gram bottle of Cefepine powder (an antibiotic medication) and a 50 milliliter (ml) bag of normal saline intravenous solution (used to liquefy the medication for administration) sitting on top of the medication cart. The medication and IV solution was visible and available to anyone in the hallway.

Licensed nurse A, (unqualified to administer IV medications) interviewed on 10/30/12 at 7:50am verified they were assigned and responsible for patient #47's patient care, however Registered Nurse B was assigned to administer patient #47's intravenous medications. Staff A reported they checked out the medication for RN B and left it setting on top of the cart. Registered Nurse B, interviewed on 10/20/12 at 7:47am verified they would mix the medication and administer to patient #47.

Observations on 10/30/12 at 9:50am of the east end of the nurse ' s station revealed an unlocked and unattended Omnicell Mobile medication cart with an intravenous bag of Ciprofloxicin 400 milligrams (an antibiotic medication) laying on top of the cart. Registered Nurse C after 10 minutes returned to the cart to retrieve the unattended medication stated they were obtaining this antibiotic for patient #33.

Nurse C, interviewed at 10:00am verified the nursing staff should not leave patient medications unattended on the top of unlocked medication cart available for unauthorized persons.