HospitalInspections.org

Based on a review of documentation and a tour of the facility, the departments responsible for the facility's building and equipment maintenance were not in compliance with the quality assurance requirements.

Findings were:

During a review of fire drills conducted during the 12-month period of 4-1-09 through 3-31-10, documentation revealed that the facility conducted only 1 fire drill during that time period (on 6-11-09).

During a tour of the patient care unit on 4-1-10, 1 of 1 medication room was found unlocked.

During a tour of the patient care unit on 4-1-10, 1 of 1 medication room contained a zippered plastic bag with 12 home medications belonging to patient #31.

During a tour of the patient care unit on 4-1-10, 1 of 1 medication room contained a zippered plastic bag with 3 home medications belonging to patient #30.

During a tour of the patient care unit on 4-1-10, 1 of 6 vials of insulin found in the medication refrigerator had been accessed but was neither dated nor initialed.

During a tour of the patient care unit on 4-1-10, 1 of 1 supply room was found unlocked and contained supplies that would be toxic if ingested.

During a tour of the patient care unit on 4-1-10, there was no documentation to show that the patient nourishment refrigerator temperature had been checked and was within the acceptable range for 9 of the 31 days in the month of March 2010.

During a tour of the critical care unit on 4-1-10, there was no documentation to show that 1 of 1 crash cart had been checked and that all equipment was operable for 33 of the 62 checks in the month of March 2010.

During a tour of the critical care unit on 4-1-10, 1 of 1 crash cart was found unlocked.

During a tour of the newborn nursery on 4-1-10, the nursery door was found unlocked.

During a tour of the newborn nursery on 4-1-10, 1 of 1 vial of calcium chloride was found to have expired 2-09 but was still available for patient use.

During a tour of the newborn nursery on 4-1-10, 1 of 1 vial of sodium bicarbonate was found to have expired 7-09 but was still available for patient use.

During a tour of the newborn nursery on 4-1-10, 1 of 1 vial of gentamycin was found to have expired 2-09 but was still available for patient use.

During a tour of the newborn nursery on 4-1-10, 2 of 2 ampules of epinephrine were found to have expired 1-1-10 but were still available for patient use.

During a tour of the newborn nursery on 4-1-10, 1 of 1 250 ml bag of intravenous sodium chloride was found to have expired 8-09 but was still available for patient use.

During a tour of the newborn nursery on 4-1-10, 1 of 1 unlocked case marked " pedi code drugs " was found on the counter of the unlocked medication room.

During a tour of the pharmacy on 4-1-10, there was no documentation to show that the refrigerator temperature had been checked on 2 of 2 medication refrigerators and was within the acceptable range for 3 of the 31 days in the month of March 2010.

During a tour of the surgery area on 4-1-10, there was no documentation to show that the refrigerator temperature had been checked on 1 of 1 patient nourishment refrigerator and was within the acceptable range for 26 of the 31 days in the month of March 2010.

During a tour of the surgery area on 4-1-10, there was no documentation to show that the refrigerator temperature had been checked on 1 of 1 anesthesia medication refrigerator and was within the acceptable range for 9 of the 31 days in the month of March 2010.

During a tour of the surgery area on 4-1-10, the anesthesia medication & supply room was found unlocked.

During a tour of the surgery area on 4-1-10, 1 of 1 ampule of methergine in the anesthesia refrigerator was found to be expired but still available for patient use.

During a tour of the surgery area on 4-1-10, 1 of 1 ampule of pontocaine in the anesthesia refrigerator was found to be expired but still available for patient use.

During a tour of the surgery area on 4-1-10, 2 of 2 50ml bags of normal saline in the anesthesia refrigerator were found to be expired but still available for patient use.

During a tour of the surgery area on 4-1-10, 2 of 2 100 m. bags of normal saline in the anesthesia refrigerator were found to be expired but still available for patient use.

During a tour of the surgery area on 4-1-10, the epidural medication cart was found to be unlocked.

During a tour of the surgery area on 4-1-10, 4 of 4 vials of neostigmine in the epidural medication cart were found to be expired but still available for patient use.

During a tour of the surgery area on 4-1-10, 2 of 4 ampules of epinephrine in the epidural medication cart were found to be expired but still available for patient use.

During a tour of the surgery area on 4-1-10, 11 of 11 tubes of surgilube in the epidural medication cart were found to be expired but still available for patient use.

During a tour of the surgery area on 4-1-10, 4 of 4 bags of intravenous normal saline in the epidural medication cart were found to be expired but still available for patient use.

During a tour of the endoscopy lab on 4-1-10, 3 of 3 vials of methergine were found to be expired but still available for patient use.

During a tour of the endoscopy lab on 4-1-10, there was no documentation to show that the refrigerator temperature had been checked on 1 of 1 medication refrigerator and was within the acceptable range for 21 of the 31 days in the month of March 2010.

During a tour of the emergency room on 4-1-10, 2 of 5 intravenous bags of lactated ringers were found to be expired but still available for patient use in ER room #2.

During a tour of the emergency room on 4-1-10, 7 of 9 intravenous bags of dextrose 5% were found to be expired but still available for patient use in ER room #2.

During a tour of the emergency room intake area on 4-1-10, there was no documentation to show that the refrigerator temperature had been checked on 1 of 1 medication refrigerator and was within the acceptable range for 18 of the 31 days in the month of March 2010.

During a tour of the emergency room intake area on 4-1-10, the 1 of 1 medication refrigerator/freezer was found unlocked.

During a tour of the operating room on 4-1-10, 18 of 18 vials of dantrolene in the malignant hyperthermia emergency kit were found to be expired but still available for patient use.

During a tour of the operating room on 4-1-10, 1 of 1 ampule of dextrose 50% in the malignant hyperthermia emergency kit was found to be expired but still available for patient use.

During a tour of the operating room on 4-1-10, 4 of 4 vials of lidocaine in the malignant hyperthermia emergency kit were found to be expired but still available for patient use.

During a tour of the operating room on 4-1-10, 4 of 4 vials of mannitol in the malignant hyperthermia emergency kit were found to be expired but still available for patient use.

During a tour of the operating room on 4-1-10, 2 of 2 vials of procainamide in the malignant hyperthermia emergency kit were found to be expired but still available for patient use.

The above was confirmed in a meeting with the interim CEO on the afternoon of 4-1-10 in the administrative conference room.

Based on a tour of the facility, the facility was not maintained to ensure access to and safety of patients.

Findings were:

During a tour of the newborn nursery on 4-1-10, the nursery door was found unlocked.

The above was confirmed in a meeting with the interim CEO on the afternoon of 4-1-10 in the administrative conference room.

Based on a tour of the facility, the facility did not have a preventive maintenance program to ensure that all essential patient care equipment is maintained in safe operating condition.

Findings were:

During a tour of the critical care unit on 4-1-10, there was no documentation to show that 1 of 1 crash cart had been checked and that all equipment was operable for 33 of the 62 checks in the month of March 2010.

The above was confirmed in a meeting with the interim CEO on the afternoon of 4-1-10 in the administrative conference room.

Based on a tour of the facility, there was no preventive maintenance program to ensure that drugs and biologicals were properly stored.

Findings were:

During a tour of the patient care unit on 4-1-10, 1 of 1 medication room was found unlocked.

During a tour of the critical care unit on 4-1-10, 1 of 1 crash cart was found unlocked.

During a tour of the newborn nursery on 4-1-10, 1 of 1 unlocked case marked " pedi code drugs " was found on the counter of the unlocked medication room.

During a tour of the surgery area on 4-1-10, the anesthesia medication & supply room was found unlocked.

During a tour of the surgery area on 4-1-10, the epidural medication cart was found to be unlocked.

During a tour of the emergency room intake area on 4-1-10, the 1 of 1 medication refrigerator/freezer was found unlocked.

The above was confirmed in a meeting with the interim CEO on the afternoon of 4-1-10 in the administrative conference room.

Based on a tour of the facility, the facility had not preventive program to ensure that there is proper ventilation, lighting and temperature control in all pharmaceutical, patient care and food preparation areas.

Findings were:

During a tour of the patient care unit on 4-1-10, there was no documentation to show that the patient nourishment refrigerator temperature had been checked and was within the acceptable range for 9 of the 31 days in the month of March 2010.

During a tour of the pharmacy on 4-1-10, there was no documentation to show that the refrigerator temperature had been checked on 2 of 2 medication refrigerators and was within the acceptable range for 3 of the 31 days in the month of March 2010.

During a tour of the surgery area on 4-1-10, there was no documentation to show that the refrigerator temperature had been checked on 1 of 1 patient nourishment refrigerator and was within the acceptable range for 26 of the 31 days in the month of March 2010.

During a tour of the surgery area on 4-1-10, there was no documentation to show that the refrigerator temperature had been checked on 1 of 1 anesthesia medication refrigerator and was within the acceptable range for 9 of the 31 days in the month of March 2010.

During a tour of the endoscopy lab on 4-1-10, there was no documentation to show that the refrigerator temperature had been checked on 1 of 1 medication refrigerator and was within the acceptable range for 21 of the 31 days in the month of March 2010.

During a tour of the emergency room intake area on 4-1-10, there was no documentation to show that the refrigerator temperature had been checked on 1 of 1 medication refrigerator and was within the acceptable range for 18 of the 31 days in the month of March 2010.

The above was confirmed in a meeting with the interim CEO on the afternoon of 4-1-10 in the administrative conference room.

Based on a review of documentation and a tour of the facility, the governing body was not responsible for ensuring that the facility policies are administered so as to provide quality health care in a safe environment.

Findings were:

Facility policy titled Multiple Dose Vial states, in part, "Multiple dose vials are dated on first use...the medical personnel that initially opens the vial for the first dose shall write the current date, time, and their initials..."

During a tour of the patient care unit on 4-1-10, 1 of 6 vials of insulin found in the medication refrigerator had been accessed but was neither dated nor initialed.

Facility policy titled Patient's Personal Medications states, in part, " 1)If a patient brings his/her own personal medications to the hospital, they will be given to the patient's family or agent. 2) If these drugs must be retained in the hospital, they will be packaged and sealed, labeled with the patient's name, and stored until returned to the patient at the time of discharge. Nursing fills out a 'Receipt for Patient's Personal Medications'. One copy of the receipt is attached to the patient's chart and the pharmacy copy is attached to the bag containing the medications. The patient's copy is given to the patient or to a family member."

During a tour of the patient care unit on 4-1-10, 1 of 1 medication room contained a zippered, unmarked plastic bag with 12 home medications belonging to patient #31.

During a tour of the patient care unit on 4-1-10, 1 of 1 medication room contained a zippered, unmarked plastic bag with 3 home medications belonging to patient #30.

Facility policy titled Medication Administration states, in part, " 8) The controlled drug supply will be audited at each shift change according to procedures outlined by the 'controlled druigs procedures - medication cart'."

Facility policy titled Controlled Drugs Procedures - Medication Cart states, in part, "The controlled drugs contained in the medication cart will be audited at each shift change by on-coming and off-going licensed personnel...At shift change, the on-coming and off-going medication nurses will record an audit of the controlled medication supply at each nursing unit, verifying the count of controlled substances and that tere is no evidence of tampering of any of the controlled medication supply."

Facility policy titled Controlled Drugs: Storage, Administratio and Wastage states, in part, "Each department will count the controlled drugs at the beginning and at the end of each shift and record the totals on the Administration Record Sheet...At shift change, the
on-coming and off-going nurses will record an audit of the controlled medication supply at each nursing unit, verifying the count of controlled substances and that there is no evidence of tampering."

During a tour of the patient care unit, the critical care unit, the newborn nursery, the surgery area and the emergency room on 4-1-10, there was no documentation to support that the controlled substances were being audited at each shift change. During a conversation with the patient care unit Charge Nurse at the time of the tour, she confirmed that a manual count of controlled substances was not performed per facility policy and that the facility relied on the electronic medication dispensing system (Omnicell) to keep track of controlled substances.

Facility policy titled Policy and Procedures for cleaning Instruments states, in part, "All instruments that have a clamping action must be packaged for autoclaving with the clamp open."

Based on a tour of the surgical area, 30 of 30 sterile instrument packs examined contained hinged instruments that had been autoclaved with the clamp in the closed position.

The above was confirmed in a meeting with the interim CEO on the afternoon of 4-1-10 in the administrative conference room.

Based on a tour of the facility, the drug storage area was not administered in accordance with accepted professional principles, current and accurate records were not kept of the receipt and disposition of all scheduled drugs and outdated, mislabeled or otherwise unusable drugs were available for patient use.

Findings were:

During a tour of the patient care unit on 4-1-10, 1 of 1 medication room was found unlocked.

During a tour of the patient care unit on 4-1-10, 1 of 1 medication room contained a zippered plastic bag with 12 home medications belonging to patient #31.

During a tour of the patient care unit on 4-1-10, 1 of 1 medication room contained a zippered plastic bag with 3 home medications belonging to patient #30.

During a tour of the patient care unit on 4-1-10, 1 of 6 vials of insulin found in the medication refrigerator had been accessed but was neither dated nor initialed.

During a tour of the critical care unit on 4-1-10, 1 of 1 crash cart was found unlocked.

During a tour of the newborn nursery on 4-1-10, 1 of 1 vial of calcium chloride was found to have expired 2-09 but was still available for patient use.

During a tour of the newborn nursery on 4-1-10, 1 of 1 vial of sodium bicarbonate was found to have expired 7-09 but was still available for patient use.

During a tour of the newborn nursery on 4-1-10, 1 of 1 vial of gentamycin was found to have expired 2-09 but was still available for patient use.

During a tour of the newborn nursery on 4-1-10, 2 of 2 ampules of epinephrine were found to have expired 1-1-10 but were still available for patient use.

During a tour of the newborn nursery on 4-1-10, 1 of 1 250 ml bag of intravenous sodium chloride was found to have expired 8-09 but was still available for patient use.

During a tour of the newborn nursery on 4-1-10, 1 of 1 unlocked case marked " pedi code drugs " was found on the counter of the unlocked medication room.

During a tour of the pharmacy on 4-1-10, the manual count for 10 of 44 controlled substances did not match the medication count in the controlled substances log.

During a tour of the surgery area on 4-1-10, the anesthesia medication & supply room was found unlocked.

During a tour of the surgery area on 4-1-10, 1 of 1 ampule of methergine in the anesthesia refrigerator was found to be expired but still available for patient use.

During a tour of the surgery area on 4-1-10, 1 of 1 ampule of pontocaine in the anesthesia refrigerator was found to be expired but still available for patient use.

During a tour of the surgery area on 4-1-10, 2 of 2 50ml bags of normal saline in the anesthesia refrigerator were found to be expired but still available for patient use.

During a tour of the surgery area on 4-1-10, 2 of 2 100 m. bags of normal saline in the anesthesia refrigerator were found to be expired but still available for patient use.

During a tour of the surgery area on 4-1-10, the epidural medication cart was found to be unlocked.

During a tour of the surgery area on 4-1-10, 4 of 4 vials of neostigmine in the epidural medication cart were found to be expired but still available for patient use.

During a tour of the surgery area on 4-1-10, 2 of 4 ampules of epinephrine in the epidural medication cart were found to be expired but still available for patient use.

During a tour of the surgery area on 4-1-10, 11 of 11 tubes of surgilube in the epidural medication cart were found to be expired but still available for patient use.

During a tour of the surgery area on 4-1-10, 4 of 4 bags of intravenous normal saline in the epidural medication cart were found to be expired but still available for patient use.

During a tour of the endoscopy lab on 4-1-10, 3 of 3 vials of methergine were found to be expired but still available for patient use.

During a tour of the emergency room on 4-1-10, 2 of 5 intravenous bags of lactated ringers were found to be expired but still available for patient use in ER room #2.

During a tour of the emergency room on 4-1-10, 7 of 9 intravenous bags of dextrose 5% were found to be expired but still available for patient use in ER room #2.

During a tour of the emergency room intake area on 4-1-10, the 1 of 1 medication refrigerator/freezer was found unlocked.

During a tour of the operating room on 4-1-10, 18 of 18 vials of dantrolene in the malignant hyperthermia emergency kit were found to be expired but still available for patient use.

During a tour of the operating room on 4-1-10, 1 of 1 ampule of dextrose 50% in the malignant hyperthermia emergency kit was found to be expired but still available for patient use.

During a tour of the operating room on 4-1-10, 4 of 4 vials of lidocaine in the malignant hyperthermia emergency kit were found to be expired but still available for patient use.

During a tour of the operating room on 4-1-10, 4 of 4 vials of mannitol in the malignant hyperthermia emergency kit were found to be expired but still available for patient use.

During a tour of the operating room on 4-1-10, 2 of 2 vials of procainamide in the malignant hyperthermia emergency kit were found to be expired but still available for patient use.

During a tour of the patient care unit, the critical care unit, the newborn nursery, the surgery area and the emergency room on 4-1-10, there was no documentation to support that the controlled substances were being audited at each shift change. During a conversation with the patient care unit Charge Nurse at the time of the tour, she confirmed that a manual count of controlled substances was not performed per facility policy and that the facility relied on the electronic medication dispensing system (Omnicell) to keep track of controlled substances

The above was confirmed in a meeting with the interim CEO on the afternoon of 4-1-10 in the administrative conference room.

Based on a tour of the facility, surgical services were not being provided in a safe manner.

Findings were:

During a tour of the operating room on 4-1-10, 18 of 18 vials of dantrolene in the malignant hyperthermia emergency kit were found to be expired but still available for patient use.

During a tour of the operating room on 4-1-10, 1 of 1 ampule of dextrose 50% in the malignant hyperthermia emergency kit was found to be expired but still available for patient use.

During a tour of the operating room on 4-1-10, 4 of 4 vials of lidocaine in the malignant hyperthermia emergency kit were found to be expired but still available for patient use.

During a tour of the operating room on 4-1-10, 4 of 4 vials of mannitol in the malignant hyperthermia emergency kit were found to be expired but still available for patient use.

During a tour of the operating room on 4-1-10, 2 of 2 vials of procainamide in the malignant hyperthermia emergency kit were found to be expired but still available for patient use.

Based on a tour of the surgical area, 30 of 30 sterile instrument packs examined contained hinged instruments that had been autoclaved with the clamp in the closed position.

The above was confirmed in a meeting with the interim CEO on the afternoon of 4-1-10 in the administrative conference room.