HospitalInspections.org

Based on patient record review, facility staff interview and facility policy and procedure review, the facility failed to ensure 4 (Patients #4, #5, #6, and #7) of 7 medical records were complete within 30 days of discharge.

The findings included:

A review of Patients #4, #5, #6 and #7's closed records showed they were discharged from the hospital on 9/18/17, 10/3/17, 8/20/17 and 9/27/17 respectively.

On 11/27/17 at 1:30 p.m., the medical records staff said these four patient records are not closed as of yet. There are a "multitude of items missing" from their records such as: discharge summary, physician orders not signed, consultations not signed, restraint orders not signed and blood transfusion orders not signed.

A review of the facility's policy on Health Information Management, policy #HIM.I.013, revised 9/14/17, shows on page 2, #7: "A medical record is considered to be delinquent if it remains incomplete 30 days after discharge."

The medical records staff reviewed this policy and confirmed Patients' #4 through #7 had been discharged from the hospital for more than 30 days and their records are not complete.

Based on observations, facility staff interviews and facility record review, the facility failed to ensure prescribed medications are secured from unlicensed staff.

The findings included:

On 11/27/17 at 11:30 a.m., a tour of the hospital was conducted with Staff A from housekeeping. Observation showed Staff A opened the medication room (by using a code to unlock the door) in the 100 hall. He also gave the code to the surveyor. Staff A said he is not a licensed nurse. Observation of this room showed several prescribed medication that were in blue bins unsecured. These medications were: Magic mouth wash which includes: Lidocaine Viscous, Maalox and Nystatin, Nova plus 40 mg, Nystatin cream, Mupirocin ointment, Gentamicin, Magnesium Hydroxide, Gilenya .5 mg and Myrbetriq ER 25 mg. Staff A said he has access to this room to clean it. A licensed nurse does not stay with him while he is in this room cleaning it.

Staff A was observed to open the medication room in the 300 hall and Progressive Care Unit. Observation of the unsecured medications in this room were: Ammonium lactate 225 mg, Symbicort, Flonase and valproate sodium 250 mg. Staff A said he cleans this room also and no licensed staff supervises him while he is in this room cleaning.

On 11/27/17 at 11:50 a.m., observation showed Staff B coming out of the medication room in the intensive care unit. She was asked if she was from housekeeping and she said yes. There was no other staff in that medication room while Staff B was in that room. In that medication room, the following medications were unsecured: Mupirocin ointment and Cipro.

The facility's policy and procedure of "Pharmaceutical Services" policy #PS.17, revised on 4/17, showed on page 2, #3: "Access to medication rooms is limited to pharmacy personnel and persons authorized to handle and administer medications. The medical staff, administration, other disciplines, housekeeping, and other personnel are allowed in medication storage units only in conjunction with their duties and under supervision."

On 11/27/17 at 2:45 p.m., the Pharmacist reviewed this policy and confirmed these medications were unsecured and unlicensed staff had access to these medications.