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Based on observation, interview, and a review of policies/procedures, the facility failed to ensure that all medications available for patient use had not exceeded the timeframe of the manufacturer's recommendation for use or that the medications were usable. A tour of the Operative/Recovery areas, the Emergency Department, Respiratory Therapy Department, and the Radiology Department on April 21, 2010, revealed numerous medications that had expired and/or were unusable. Interviews revealed the facility staff had failed to observe the expired medications and had failed to properly dispose of the unusable medications. A review of the facility policies and procedures revealed medications that were unusable were to be disposed.

The findings include:

1. A tour of the anesthesia room of the facility's operative suite on April 21, 2010, at 3:12 PM Eastern Daylight Savings Time (EDST), revealed a five-milliliter ampule of Fentanyl (Narcotic/opioid analgesic) that had been opened/exposed and was contained in a drawer of the anesthesia cart. Interview with the CRNA (Certified Registered Nurse Anesthetist) on April 22, 2010, at 1:50 PM EDST, revealed the CRNA had opened the ampule of Fentanyl (Narcotic/opioid analgesic) on April 21, 2010, in anticipation of surgical/diagnostic procedures that had been scheduled for April 21, 2010. However, according to the CRNA, several of the procedures had been canceled and the CRNA had failed to dispose of the opened/exposed medication on April 21, 2010.

2. A tour of the Procedure Room, located in the Operating Room Suite, on April 21, 2010, at 2:41 PM EDST, revealed six vials of Sodium Chloride that had expiration dates of November 1, 2009. There was also a 16-fluid ounce bottle of full strength Dakins solution, that was observed to be approximately half-full, with an expiration date of January 2008, that was available for patient use. There were five Pediatric Emergency Systems that had expiration dates of April 2008, and six Pediatric Emergency Systems that had expirations dates of April 2007, that were available for patient use.

3. A tour of the Radiology Department on April 21, 2010, at 3:30 PM EDST, revealed the emergency drug box located in the CT room contained the following: one 30-milliliter (ml) bottle of Dexamethasone Sodium Phosphate with an expiration date of March 10, 2010; a two-ml vial of Lanoxin with an expiration date of November 2009, and a bottle of 2% Lidocaine HCL with an expiration date of December 2009. The emergency drug box located in the Radiography and Fluoroscopy Room contained the following: two vials of Lanoxin that expired in October 2009; one 30-ml bottle of Dexamethasone Sodium Phosphate with an expiration date of March 10, 2010, and a bottle of 8.4% Sodium Bicarbonate Injection, expired January 1, 2010.

4. A tour of the Respiratory Department on April 21, 2010, at 5:00 PM EDST, revealed one Ventolin inhaler that expired in November 2009 and one Xopenex HFA inhaler that expired in March 2009. One inhaler had a worn, illegible label.

5. A tour of the Emergency Department on April 21, 2010, at 12:50 PM EDST, revealed one multi-dose bottle of 1% Lidocaine that expired on September 1, 2009.

A review of the facility policies and procedures revealed medications that were unusable were to be disposed.

An interview with the Chief Nursing Officer on April 21, 2010, at 12:50 PM EDST, revealed that nursing staff was required to check the medication storage areas at least monthly for expired medications.

Interview with the Pharmacist on April 21, 2010, at 11:30 AM EDST, revealed the Pharmacy Department staff was required to check the medication storage areas throughout the facility monthly. However, the pharmacist revealed the inspection of the medication storage areas was not documented.

On March 22, 2010, the CEO provided a form that was required to be utilized by the Pharmacy Department staff to check for outdated/expired medications; however, the interview with the Pharmacist on April 21, 2010, at 11:30 AM EDST, revealed this form was not being utilized by the Pharmacy Department staff.

Based on interviews and review of the facility's policies and procedures, it was determined the facility failed to have a Utilization Review Committee that consisted of two (2) or more practitioners to carry out the utilization review functions.

The findings include:

An interview was conducted with the Utilization Review (UR) Coordinator on April 22, 2010, at 4:10 PM. The UR Coordinator stated the facility did not have a separate UR Committee. The UR Coordinator stated that any problems with the utilization review was directed to the facility Administrator and these problems were reported in the medical staff meetings by the Administrator. The UR Coordinator stated the UR Coordinator did not attend the medical staff meetings.

An interview was conducted with the Administrator on April 22, 2010, at 4:55 PM. The Administrator stated any concerns or problems with UR was discussed in the medical staff meetings, but the concerns or findings were not documented.

A review of the facility's UR policies and procedures was conducted on April 22, 2010, at 3:30 PM. The facility policy revealed the facility would have a UR Committee consisting of a Chairman, who is a member of Hospital Administration, and two or more members of the medical staff. Additional members include representatives from Hospital Administration, Discharge Planning, Admitting Office, Nursing Services, Business Office, and Medical Records. According to the policy, the UR Committee was required to meet a minimum of once a month and maintain a written record of these meetings.

A review of the facility's Medical Staff Meeting Minutes was conducted on April 22, 2010, at 4:25 PM. This review revealed no documented evidence of UR concerns or problems discussed in the medical staff meetings.

Based on interviews, a review of medical staff bylaws, and a review of credentialing files, the facility failed to ensure the organization of anesthesia services was appropriate to the scope of the services offered. The facility failed to ensure the medical staff bylaws included criteria for the determination of the privileges for the certified registered nurse anesthetist (CRNA) for one (1) of one (1) CRNAs utilized by the facility.

The findings include:

Interview with the Operating Room (OR) Nursing Director on April 21, 2010, at 2:35 PM, and a review of the facility's operative procedure log book revealed anesthesia services, which included general and epidural anesthesia for invasive/noninvasive operative procedures, were provide by a CRNA. Interview with the facility's Administrator on April 22, 2010, at 3:21 PM, and a review of services provided under contract at the facility, revealed the services of the CRNA had been obtained by contract with an outside agency. A review of documentation provided by the facility revealed evidence of the CRNA's credentials, however, the facility failed to provide documentation of the CRNA's anesthesia privileges.

A review of the facility's medical staff bylaws revealed the facility failed to ensure the bylaws included criteria for the determination of privileges granted to the CRNA and failed to include a procedure for the application of the criteria to the practitioner's requested privileges. In addition, the facility failed to identify the type and complexity of procedures for which the CRNA could administer anesthesia.

Based on interviews and observation, the facility failed to ensure timely accessibility of emergency services for patients seeking emergency diagnosis/treatment at the facility.

The findings include:

Interview with the Safety Officer at 2:30 PM on April 22, 2010, revealed there were two facility entrances which were utilized by patients to gain entrance into the Emergency Department. These two entrances were the front entrance, which was the main entrance into the facility, and the entrance leading directly into the Emergency Department, which was utilized by ambulance personnel transporting patients to the Emergency Department. The interview revealed the main entrance was locked at 9:00 PM, to ensure safety/security of the staff and patients. The ambulance entry was locked 24 hours a day, according to the Safety Officer.

Interview with the Director of Nurses (DON) on April 22, 2010, at 12:20 PM, revealed the facility had an intercom with a push button bell that rang into the Emergency Department. The intercom was located at the main entrance into the facility and at the ambulance entrance leading into the Emergency Room. The intercom enabled patients to verbally communicate to Emergency Room staff their desire to obtain emergency treatment. The interview further revealed the ambulance personnel had a code that could be used to enter the Emergency Department through the emergency ambulance entrance. Video cameras were located at these locked entrances and were monitored at the nurses' station in the Emergency Department and at the Receptionist desk at the main entrance according to the DON. The entrance doors could be unlocked by the Emergency Department staff from the Emergency Room. Interview further revealed there was no staff located at the cameras in the Emergency Room or the Receptionist's desk at all times when the entrances were locked.

Interview with the Receptionist on April 22, 2010, at 3:00 PM, revealed the Receptionist, who was located at a desk inside the main entrance to the facility, left the facility at 3:30 PM.

An interview was conducted on April 22, 2010, at 2:55 PM, with the Registration staff, who was responsible for admitting patients to the hospital and Emergency Room. The interview revealed the Registration staff was located behind a glass window near the main entrance. The Registration staff revealed the Registration staff was on duty from 6:00 AM to 2:00 AM. The interview revealed that after 2:00 AM, the Emergency Room staff registers the Emergency Room patients.

Interview with the Safety Officer on April 22, 2010, at 2:30 PM, revealed the security guard was on duty from 7:00 PM to 7:00 AM each day, and was responsible for monitoring the cameras for patients requesting entrance into the facility to obtain emergency care/treatment. The Safety Officer stated that at 9:00 PM, the security guard monitored the cameras from the Emergency Department. However, the security guard's responsibilities included touring the entire facility at intervals throughout the security guard's shift, therefore, the cameras could not be monitored at all times.

Observation on April 22, 2010, revealed the ambulance entrance into the Emergency Room had a sign posted outside the doors that stated "Non-Emergency Patients use front entrance." The doors to the Emergency Room also stated "Ambulance Only." When patients entered the main entrance after 2:00 AM, when there was no staff at Registration and no Receptionist, there was no signage directing patients to the Emergency Room.

An interview with the Chief Operating Officer (CEO) on April 22, 2010, revealed the facility did not have a policy/procedure regarding monitoring of the video cameras.