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Based on medical record review, interview and document review, hospital staff did not identify that an order for a twice per day medication entered into the electronic medical record for Patient #1 defaulted to a PRN (as needed) frequency. The default to a PRN frequency has the potential to result in missed medications.

Findings include:

Review of Health Production System-Home Medication Frequencies revealed when a patient is admitted and staff are updating the home medications, a frequency written as "two times per day" must be changed to "two (2) times per day". If the order is not changed, the system cannot recognize the format and times will not be assigned. Without an assigned time, the medication is placed in the PRN section of the medication administration record (MAR).

Review of Physician Orders for post-operative anti-convulsant medications for Patient #1 dated 04/06/17 at 11:50 AM revealed the following:
- Neurontin 800 mg (2) times per day
- Lamictal 400 mg two times per day
- Aptiom 800 mg daily
- Lamictal 100 mg at bedtime

Review of the MAR for Patient #1 from 04/06/17 to 04/09/17 revealed the order for Lamictal 400 mg two times per day was not administered.

Interview with Staff B and D on 05/08/17 at 01:30 PM revealed since the order for Lamictal 400mg two times a day was not written in the required manner, the medication frequency defaulted to PRN.

Based on observation and interview, the facility does not ensure the safety and security of sharps containers. This has the potential for staff or patient injury.

Findings include:

Observation on 5/9/17 at 11:00 AM in Operating Rooms #7 and #8 revealed large sharps containers on the floor next to the anesthesia machines. The lids on the sharps containers were open and the containers were not placed in a safety securing device to prevent tipping and spillage of contents.

Interview with Staff T and U on 5/9/17 at 11:15 AM verified these findings.

Based on document review, policy and procedure review and interview, surgical staff did not follow facility policy related to allergy assessment and universal protocol for invasive procedures. Specifically documentation of allergies in the medical records were inconsistent, or not documented in 8 of 20 medical records reviewed and abbreviation for laterality on surgical consent was documented in 1 of 20 medical records reviewed. Failure to adhere to facility policies increases the potential for an adverse patient event to occur.

Findings include:

Review of facility Policy and Procedure titled "Patient Allergy," last reviewed 01/17 revealed the authorized practitioner is responsible for allergy documentation and clarification of specific effect. The nurse shall obtain allergy information to include the specific effects or allergic reaction noted. Questions related to the patient's allergy history shall be directed to the authorized practitioner for clarification/authorization prior to executing any questionable drug orders. The nurse shall appropriately document any authorized practitioner clarification.

Review of the medical record for Patient #1 on 5/8/17 revealed Iodine (anaphylaxis) and Latex allergy. Review of Anesthesia Pre-op Evaluation dated 4/6/17 at 10:48 AM revealed documentation of Iodine allergy. Latex allergy not documented on this evaluation. Review of Anesthesia Intra-op Record dated 4/6/17 at 11:06 AM revealed under Allergies/Reactions: No Known Drug Allergy. Review of Nursing Intra-op Record dated 4/6/17 at 11:06 AM revealed 1/2' Iodoform packing, which contained Iodine, was used.

Review of the medical record for Patient #2 on 5/9/17 revealed allergies to Penicillin, Predisone, Keflex, Efavirenz and Truvada on SDS (same day surgery) Admission Assessment dated 5/9/17. Review of Anesthesia Pre-op Evaluation revealed No Drug Sensitivities. Review of Orthopedic/Podiatry Admission Orders dated 5/9/17 at 07:50 AM revealed the area for allergy documentation was left blank.

Review of the medical record for Patient #6 on 5/9/17 revealed allergy documentation of Augmentin and Tape. Review of Orthopedic/Podiatry Admission Orders dated 5/9/17 at 10:05 revealed the space for allergy documentation was left blank.

Review of the medical record for Patient #10 on 5/9/17 revealed the space for allergy documentation on the physician orders was left left blank.

Review of the medical record for Patient #11 on 5/9/17 revealed the "booking sheet" listed Doxycycline as an allergy yet the physician order sheet did not address the allergy.

Review of the medical record for Patient #16 on 5/9/17 revealed the preadmission assessment and anesthesia pre-op evaluation documented IVP dye as an allergy, yet the anesthesia record documented no known drug allergy. The allergy section in the physician orders was left blank.

Review of the medical record for Patient #17 on 5/9/17 revealed no allergy documentation on physician orders for Total Joint Admission orders and Level of Care/Admission and Certification orders.

Review of the medical record for Patient #18 on 5/9/17 revealed the history and physical exam documents numerous allergies. The physician orders for surgery revealed the space for allergy documentation was left blank.

Review of facility Policy and Procedure titled "Universal Portocol for Invasive Procedures," revised 03/15 stated the following: "The words "left or "right" must be spelled out whenever laterality is an issue."

Review of the medical record for Patient #6 revealed abbreviation for laterality on Operative Consent dated 05/09/17. Consent stated the following operative procedure: "Left Knee Arthroscopy, Rt. elbow medial epicondyle injection."

Interview with Staff B, C and D on 5/9/17 at 03:30 PM verified these findings.

Based on medical record review, document review and interview, the facility did not ensure that a complete preoperative evaluation was documented in 1 of 20 medical records reviewed (Patient #1). This has the potential to place patients at risk for an adverse event.

Findings include:

The Department of Anesthesiology Rules and Regulations, last revised 02/11 states that the Pre-anesthetic evaluation within 48 hours prior to surgery requires that the anesthesiologist review the chart, including pre-operative diagnostic data. The patient's medical history, anesthesia history and medication history are to be reviewed. Medication recommendation is for the patient to take all of their prescribed medications with a sip of water the morning of surgery. Medications that should be held include diuretics, ace inhibitors, Coumadin and Plavix.

Review of physician History and Physical dated 04/05/17 at 05:27 PM for Patient #1 revealed the patient had a history of seizure disorder and was currently receiving Diastat rectal syringe for seizure activity lasting more than 4 minutes or a cluster of 3, Aptiom 800 mg daily, Lamictal 100 mg daily at bedtime, Lamictal 400 mg daily twice a day and Neurontin 800 mg twice a day. It was noted that the medications were started and that the nurse would call the facility where the patient resided for the Aptiom in the morning.

Review of Anesthesia Pre-op Evaluation dated 04/06/17 at 10:48 AM revealed the patient's medication list included
Magnesium, Lotrel, Lamictal, Diastat and Neurontin. Aptiom was not noted and there is no documentation to indicate that the patient recieved the morning doses of anticonvulsants prior to surgery.

Telephone interview with Staff DD, Director of Anesthesia on 05/10/17 at 03:00 PM revealed all current medications are reviewed by anesthesia pre-operatively and necessary medications should be taken with sips of water on morning of surgery. Anticonvulsants should be reviewed by anesthesia and taken prior to surgery.

Interview with Staff B on 05/10/17 at 03:15 PM verified these findings.