HospitalInspections.org

Based on surveyor observations, document review, and interview, it was determined the hospital failed to ensure each patient received care in a safe setting. Specifically, the hospital failed to ensure medications were secured in three (3) of three (3)observations conducted during the survey.

Findings:

A tour was conducted on the 5th floor medical unit at 9:45 AM on 12/15/21. The Medical Facilities Inspector (MFI) observed multiple wrapped, unattended saline flushes on a computer on wheels cart in the hallway. The MFI observed a second computer on wheels cart on the same hallway with an open vial of insulin and insulin syringes and needles on the top of the cart, with no staff member in the visual vicinity of the area. The MFI alerted the Director of the Unit who was accompanying the MFI on the tour. The Director confirmed the medications should not be left unattended on the cart and removed the insulin from the area.

A second observation of the 5th floor medical unit was conducted on 12/16/21 at 11:08 AM. The MFI observed a unit dose of albuterol/atrovent for inhalation unattended on a computer on wheels cart. The Manager of the 5th floor confirmed the unattended medication and that the medication should not be left unsecured.

The MFI then made observations on the 4th floor surgical unit. The following medications were observed to be unattended on top of the computer on wheels cart: Cefazolin 1 gram IV (two vials); Senna tablet; Colace, Gabapentin, Tylenol, and Celebrex. After approximately one minute, the staff nurse returned to the computer and the unattended medications. The staff nurse stated [s]he had briefly stepped away from the medications and acknowledged the medications should not have been left unattended.

The MFI requested the hospital's policy for the storage of medications to include safety related to the secure storage of medications during/prior to administration. The hospital's Vice President of Quality stated that the hospital did not have such a policy but provided the MFIs with a document presented to staff at a daily safety huddle with the heading: What Items Must Always Be Secured that contained pictures of saline flushes, needles, mediations, vaccines, scalpels and medical records. A second document with the heading, Computer on Wheels, contained the following: Your Computer on Wheels (COW) goes in and out of patient rooms. Don't keep your beverage bottles, food and drinks and personal belongings on it. You risk picking up a serious infection and carrying the infection home to your family. Keep the drawers locked when you are leaving it unattended, including when you run into a patient room leaving the COW outside. If you leave medications and sharps in a COW with an unlocked drawer, they are considered unsecured. A third document provided to the MFI partially reads as follows: Unsecured Medications: If anyone other than you can lay their hands on the medication, it is not secured...if it is on your COW and you have stepped away...Yes, saline is considered a medication.

The hospital's Vice President of Quality and Patient Care coordinator confirmed the medications should not have been left unsecured after the observations on 12/16/21 and again during the exit conference on 12/16/21.