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Based on observation, staff interview and policy review, the facility failed to ensure a drug storage area that is administered in accordance with accepted professional principles; failed to ensure that current and accurate records are kept of the receipt and disposition of a scheduled drugs; failed to ensure that outdated, mislabeled, or otherwise unusable drugs are not available for patient use; failed to ensure that direct services, including assessment of health status, were provided; failed to follow their own policy of checking controls on glucometers; and failed to ensure that a nursing care plan is developed and kept current for each inpatient.


Findings include:


Cross Refer to C-0276 485.635(a)(3)(iv) for the facility's failure to ensure a drug storage area that is administered in accordance with accepted professional principles; that current and accurate records are kept of the receipt and disposition of a scheduled drugs; and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use.


Cross Refer to C281 485.635(b) for the facility's failure to ensure that direct services, including assessment of health status (pain assessments), were provided for Patient #4, #5 and #10.


Cross Refer to C282 485.635(b)(2) for the facility's failure to ensure quality control assessments were done daily on glucometers.


Cross Refer to C298 485.635(d)(4) for the facility's failure to ensure that a nursing care plan was developed and kept current for acute care Inpatient #14 and #16.

Based on observation, staff interview and policy review, the facility failed to ensure a drug storage area that is administered in accordance with accepted professional principles; that current and accurate records are kept of the receipt and disposition of a scheduled drugs; and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use.


Findings include:


Observation of the Emergency Room (ER) on 11/13/2012 at approximately 10:30 a.m. revealed that the entrance door to the medication room was not locked. When Registered Nurse (RN) #1 was asked if there were narcotics in the ER she stated, "They are stored in the medication cabinet." RN #1 was then asked if the door to the medication room was routinely left unlocked. She stated, "Yes. There are not enough keys to the door, so it is left unlocked."


Observation of the medical/surgical floor on 11/13/2012 at approximately 11:00 a.m. revealed that the entrance door to the medication room was ajar. When asked about the door RN #1 stated, "It will not lock." Observation inside the medication refrigerator, located in the medication room, revealed the following medications:
1. 31 bottles of Ativan 2mg/ml (milligram/milliliter) vials;
1. Three (3) vials of Humulin R insulin with no open date or expiration date;
3. Two (2) vials of Levimir insulin with no open date or expiration date;
4. One (1) bottle of Lantus insulin with no open date;
5. One (1) vial of Humalog 75/25 insulin with no open date or expiration date.

RN #1 removed the insulin from the refrigerator and stated "I don't know why they are not dating these, I have done in-services." Sitting on a table to the right of the medication refrigerator was a blue basket filled with various medications. None of the medication bottles were labeled with patient names or room numbers. The medications in the basket were:
1. Pantoprazole (four [4] tablets);
2. Milk of Magnesia 30ml;
3. Nystatin/Sulfamethozole/Trimethoprin 800/160;
4. Nystatin 500,000 units;
5. Loratidine 10mg;
6. Nexium 20mg (two [2] tablets);
7. Loperamide 2mg (two (2) tablets);
8. Seraquel 50mg;
9. Omeprazole 20 mg;
10. Ramipril 2.5mg (two (2) tablets);
11. Furosemide (Lasix) 40mg;
12. Diphenhydramine 25mg;
13. Lanoxin 125mcg (microgram) {two [2] tablets};
14. Lipitor 20mg; and
15. One (1) pill in a blister packet with the medication's name torn off.

The Licensed Practical Nurse (LPN) (#1), in the medication room during observations, was asked why the medications were in the basket. She stated, "We pull our medications in the mornings and if any medications have been discontinued or if the patient refuses a medication we put them in the basket and after noon, when it slows down, we return them." When asked how they knew who to return them to since none of the medications had patient names, LPN #1 stated, "We use our medication administration records (MAR)."

Review of the facility's "Storage of Medications and Solutions in Patient Care Areas" policy (effective 10/01/2010) revealed, "Procedure: (Bullet #7) Each Patient's medications are stored separately from other patient's medications. (Bullet #9) Drugs shall be kept in locked storage when unattended and shall be inaccessible to unauthorized individuals. (Bullet #10) Controlled drugs not stored in the Pharmacy, shall be accessible only to licensed medical, nursing, or Pharmacy personnel. (Bullet #15) Refrigerated insulin must be dated when opened and discarded after six (6) months. 19: Record open and discard dates on solution bottles."

Based on record review, staff interview, and policy review, the facility failed to ensure that direct services, including assessment of health status (pain assessments), were provided for three (3) of ten (10) patients reviewed, Patient #4, #5 and #10.


Findings include:


Record review for Patients #4, #5, and #10 revealed no documented evidence of any pain assessments.


During an interview on 11/13/2012 at approximately 2:30 p.m. Registered Nurse (RN) #1 was asked how their patient's pain was assessed when they were admitted into the Emergency Room. She stated, "It seems like when we get one thing fixed and move on to something else, the nurses stop."


Review of the facility's "Pain assessment, Reassessment and Management" policy (effective 10/01/20120) revealed, "Procedure: (Bullet #1) It is the responsibility of all clinical staff to assess and periodically reassess the patient for pain and relief from pain including the intensity and quality... (Bullet #2) At the time of admission to the facility, the patient will be questioned regarding pain during the initial nursing assessment."

Based on review of glucometer control logs, staff interview and policy review, the facility failed to ensure quality control assessments were done daily on glucometers.


Findings include:


During tour of the facility on 11/13/2012 at approximately 11 a.m. control logs for the facility's glucometers was discussed with Registered Nurse (RN) #1. After obtaining the control log RN #1 stated, "The control log is here, but they (facility staff) have not been doing it every shift."


Review of the "Glucometer Daily Monitor" revealed no documented evidence that controls were being performed on the glucometer daily.


Review of the facility's "Blood Glucose Monitoring" policy (effective 10/01/2010) revealed, "Purpose: (Bullet #5) Quality control assessment shall be completed daily... If the monitoring device has not been used in 24 years, the operator will do a quality control assessment prior to use."

Based on record review, staff interview, and policy review, the facility failed to ensure that a nursing care plan was developed and kept current for two (2) of three (3) acute care inpatients reviewed, Inpatient #14 and #16.


Findings include:


Record review for acute care Inpatient #14 and #16 revealed no documented evidence that a plan of care had been initiated since their admission to the hospital.


Interview with the Director of Nurses (DON) on 11/14/12 at approximately 10 a.m. revealed, "The new admits do not have a care plan yet because we have been short staffed. I will get them done today."


Review of the facility's "Care Planning" policy (effective 10/01/2010) revealed, "Procedure: (Bullet #1) Within eight (8) hours of admission all patients shall have a plan of care generated by the registered nurse."

Based on record review, policy review and staff interview, the facility failed to ensure all medical records are promptly completed following discharge, that all entries are timed and all consents are properly executed.


Findings include:


Cross Refer to C301 for the facility's failure to ensure that all medical records are promptly completed following discharge.


Cross Refer to C304 for the facility's failure to ensure consent forms are properly executed.


Cross Refer to C307 for the facility's failure to ensure that all entries in the medical records were timed.

Based on record review and staff interview, the facility failed to ensure that all medical records are promptly completed following discharge.


Findings include:


On 11/13/12 at 2:10 p.m. a count of the incomplete physician medical record files revealed approximately 197 delinquent medical records. This count was conducted by the Medical Records Director. In an interview on 11/13/2012 at 2:30 p.m. the Medical Records Director stated, "I have not mailed any delinquent letters to physicians; all my contact has been verbal." At 3:10 p.m. the Medical Records Director confirmed that approximately 197 medical records were over 30 days delinquent, dating back to March 2012. She stated, "The delinquent medical records included acute, swing bed, observation and surgery records."

Based on record review, policy review and staff interview, the facility failed to ensure six (6) of 25 inpatient records reviewed had consent forms which were properly executed.


Findings include:


Ten (10) discharged records were selected at random from a list of recent discharges and reviewed along with 15 inpatient medical records for a total of 25 records.


In six (6) of 25 records reviewed the "Consent for Admission and Treatment" had either not been signed by the patient, not witnessed, not dated, or the person signing the consent for the patient was not identified as to their relationship to the patient.

Review of the facility's "Hospital Informed Consent" policy [effective date 01/01/2013 (?)] revealed, "Policy: (Bullet #1) A written informed consent form will be completed and entered into the medical records when the patient seeks care(general consent for care). (Bullet #2) All inpatient and outpatient medical records must contain a properly executed and completed written informed consent form for all procedures and treatments specified by the hospital's medical staff... (Bullet #4) Both the general consent for care and the specific consent for operative and invasive procedures, sedation or anesthesia...will be obtained prior to providing care..."


Five (5) of the five (5) surgical procedure records reviewed revealed that the "Consent Surgical/Medical Procedure and Acknowledgement of Receipt of Information" was not properly executed. The surgical procedure performed was not identified or written in the space provided on the consent the patient signed.


On 11/14/2012 at 1:00 p.m. in an interview with the Operating Room Manager confirmed that the consents reviewed were what the facility had been using. She stated, "I know the consents are not complete." She submitted a blank surgical consent form for review and stated, "Every consent would be specific to the patient going forward today."


On 11/14/12 at 1:15 p.m. review of the facility's "Surgical Consents" policy (effective 10/01/2010) revealed, "Policy: ...Patients must then sign an informed Surgical Consent form to evidence that they have been informed and wish to proceed with the procedure."


In two (2) of five (5) surgical procedure records reviewed, there was no documented evidence of a "History and Physical" prior to surgery.


In two (2) of 25 records reviewed, there was no documented evidence of a "Discharge Summary".

Based on record review and staff interview, the facility failed to ensure that all entries in the medical records are timed.

Findings include:

Ten (10) discharged records were selected at random from a list of recent discharges and reviewed along with 15 inpatient medical records for a total of 25 records.

In four (4) of 25 medical records reviewed, physician orders had not been timed when written in the medical record. This included orders written by the physician, verbal orders taken by the nurse, and routine orders sheets when placed in the medical record.

In eight (8) of 25 medical records reviewed, physician progress report notes had not been timed when written in the medical record.

On 11/13/2012 at 3:15 p.m. the Quality Assurance Nurse confirmed that the physician orders and progress notes were not all timed. She stated, "We have been working on this."