HospitalInspections.org

The Critical Access Hospital (CAH) reported a census of one swing bed patient and one acute care patient. Based on observation, policy review and interview the hospital failed to develop a system to monitor for outdated drugs, supplies and biologicals.

Findings include:

- Observations made on 5/10/10 in the Trauma Chest Pain room revealed the crash cart contained:
3- 10millileter (ml) disposable syringes with an expiration date of 12/08/09.

The supply closet in the Trauma Chest Pain room contained
1.) One Irrigation tray with a 60 cubic centimeter (cc) syringe with an expiration date of 3/2007.
2.) One, 18 French 30 cc hemostat with an expiration date of 10/2009.

- Observations made on 5/10/10 in the Trauma Chest Pain room revealed a Broselow Pediatric Emergency Kit which contained:

1.) One, # three Miller Laryngoscope blade
2.) Three, # two Miller Laryngoscope blades
3.) One, # one Miller Laryngoscope blade, all with an expiration date of 4/2008.
4.) One, # three Mac Laryngoscope blade and two, # two Mac Laryngoscope blade, both with an expiration date of 4/2008.
5.) One Intravenous (IV) start kit containing a 20 gauge IV catheter needle, an 18 gauge IV catheter needle and one sterile extension set with an expiration date of 3/2007.
6.) One Endotracheal tube with an expiration date of 2/2010.
7.) One, 6.5 milliliter (ml), one, 5.0 ml and one, 4.0 ml endotracheal tube, all with an expiration date of 4/2008.
8.) One, 5.5 ml endotracheal tube with an expiration date of 3/2008 and one 4.0ml endotracheal tube with an expiration date of 3/2007.
9.) Seven, Endotracheal tube Stylets with an expiration date of 4/2008.
10.) One, #12 French suction catheter with an expiration date of 4/2008.
11.) Two, #10 French suction catheter with an expiration date of 3/2007.
12.) One, #18 French Nasogastric tube with an expiration date of 4/2008.
13.) One, #14 French Nasogastric tube with an expiration date of 4/2008.
14.) Two, #10 French Nasogastric tube with expiration dates of 3/2007.
15.) One, #8 French Nasogastric tube with an expiration date of 4/2008.
16.) Seven, 10cc syringes with expiration dates of 4/2008.
17.) Seven, 36 " rolls of adhesive tape with an expiration date of 4/2008.
18.) Seven, Lubricating jelly packets with an expiration date of 4/2008.
19.) Five, 15 gauge Iliac Aspiration Needles and one sterile extension set, both which expired 2/2010.
20.) One, 14 gauge Jelco 32mm Needle with an expiration date of 12/2001.
21.) One, Endotracheal tube stylet 2.5mm-4.0mm with an expiration date of 12/09.
22.) One, Endotracheal tube uncuffed 3.5mm with an expiration date of 12/09.
23.) One, sterile duodenal tube, size 8, with an expiration date of 5/2009.

Policy review for the Crash Cart, dated April 6, 2005, revealed, ....All drugs and supplies will be kept within the expiration date....

Policy review for Storage and Labeling of Medications, effective March 23, 2005, revealed, ...11. Medication cart, controlled drug cabinet, and crash cart will be examined monthly by the pharmacy supervisor for deteriorated, outdated, and drugs not in use......

An interview with staff A on 5/10/10 at 3:00pm, acknowledged the Director of Nursing performs the checks for the outdates.

An interview with staff B on 5/12/10 at 1:20pm, confirmed they are responsible for checking for outdates on the crash cart and the medication room and all supplies.

The Critical Access Hospital (CAH) reported a census of one swing bed patient and one acute care patient. Based on observation, policy review and interview the hospital failed to develop a system to monitor for outdated, mislabeled and unusable drugs.

Findings include:

- Observations made on 5/10/10 of the nurse station medication room revealed
1.) Three vials of Epinephrine 1:1000, 1 milligram (mg) /1 ml with an expiration date of 4/10.
2.) One 100ml bottle of Lidocaine hydrochloride Oral Topical with an open date of 4/1/10. Manufacture instructions revealed the bottle must be disposed of 28 days after opening.

The refrigerator in the nurse's station medication room revealed
1.) One open bottle of Procrit 1ml that lacked a date of opening
2.) One bottle Novolin R Human Insulin with an open date of 1/2010
3.) One bottle of Lantus 100units/ml that lacked a date of opening.
4.) One bottle of Novolin 70/30 Insulin that lacked a date of opening.
5.) One bottle of Novalog Insulin with an open date of 1/06/10.

Policy review for Multidose Vials, effective date of April 15, 2005 revealed, "when multidose vials are opened or entered the following steps will be followed:
1.) a. Write the date, and initial of person opening, on the label of the vial when it is opened.
2.) f. A Multidose vial must be discarded 30 days from the date on which the vial was first opened.

Policy review for Pharmacy Supervisor, effective date of March 23, 2005, revealed, ..."7. To be responsible for the removal of all outdated drugs and related supplies from the inventory and see that they are either properly disposed of or returned to the manufacturer for credit."

Policy review for Storage and Labeling of Medications, effective date of March 23, 2005, revealed, ...11. Medication cart, controlled drug cabinet, and crash cart will be examined monthly by the pharmacy supervisor for deteriorated, outdated, and drugs not in use......

An interview with staff A on 5/10/10 at 3:30pm, confirmed that staff do not have a regular schedule to check for outdates on all medications and supplies.

An interview with staff B on 5/12/10 at 1:20pm, confirmed they are responsible for checking for outdates on the crash cart and the medication room and all supplies.

Based on record review, policy review and interview, the hospital failed to ensure multiple practitioners (physicians and physician assistants) dictated patient history and physicals within 24 hours after admission for 11 of 20 patients (#13, 14, 17, 19, 20, 21, 24, 26, 27, 29 and 30) and failed to ensure multiple practitioners dictated patient discharge summaries within 24 hours after discharge for 9 of 18 (#14, 15, 17, 18, 20, 21, 22, 23 and 31) patients per Medical Staff Bylaws and hospital policy.

Findings include:

- The hospital's 5/01/03 policy titled "Medical Record Guideline for Physicians" directed "...A complete admission history and physical examination shall be recorded within 24 hours of an acute admission...A discharge summary shall be completed within 24 hours of discharge...".

- The hospital's 10/2010 Medical Staff Bylaws directed "...History and Physicals shall be completed within the first 24 hours of admission...A discharge summary shall be completed within 24 hours of discharge...".

- The hospital admitted patient #17 on 4/30/09 with diagnoses of atrial fibrillation and congestive heart failure and discharged the patient on 5/4/09. Record review revealed physician assistant H dictated the patient' s history/physical on 5/2/09, (two day after the admission) and hospital staff transcribed the history/physical on 5/4/10. Record review evidenced physician assistant H dictated the patient' s discharge summary on 5/13/10, (nine days after the patient 's discharge) and hospital staff transcribed the summary on 5/14/10.
The hospital admitted patient #18 on 6/3/09 with diagnoses of confusion, weakness and pneumonia and discharged the patient on 6/8/09. Record review revealed physician assistant H dictated the patient's discharge summary on 6/25/09 (17 days after discharge).
The hospital admitted patient #27 on 8/5/09 with a diagnosis of abdominal pain with nausea and vomiting and discharged the patient to the Swing Bed Program on 8/9/09. Record review revealed physician assistant H dictated the patient's history/physical on 8/18/09 (13 days after the patient's acute inpatient admission). Record review evidence physician assistant H dictated the patient's discharge summary on 8/11/09.
Staff D on 5/11/10 at 8:10am acknowledged all history and physicals are to be on the patient chart within 24 hours. Staff B shared if we get them dictated it can be up to three days before they are placed on the chart.
Staff J on 5/12/10 at 10:00am acknowledged practitioners should complete history and physicals within 24 hours of admission and they should complete discharge summaries within 24 hours of discharge.
The failure to complete history and physicals within 24 hours of admission and discharge summaries 24 hour of discharge also affected patients #13, 14, 15, 19, 20, 21, 22, 23, 24, 26, 29, 30 and 31.

The Critical Access Hospital (CAH), reported a census of two patients. The two active records and 18 closed records were chosen for review. Based on record review, policy review and interview, multiple practitioners: physicians and PA (physician assistants) and nursing staff failed to document the time when they wrote physician orders and multiple practitioners failed to document the date and time when they authenticated their orders for 20 of 21 patients (#12, 13, 14, 15 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 and 31).

Findings include:

- The hospital admitted Patient #16 on 5/6/10 with a diagnosis of congestive heart failure: acute exacerbation. Record review revealed multiple practitioners and nursing staff failed to document the time when they wrote physician orders and multiple practitioners failed to document the date and time when they authenticated their orders.

For example:

1. Licensed nurse B on 5/6/10 obtained a physician order for a Foley catheter, a urine analysis, daily weights, intake and output, Telemetry and Ground meat with gravy to diet. Record review evidenced the nurse failed to document the time they obtained the order from the practitioner.

2. Physician assistant E on 5/7/10 wrote an order for Lasix (a diuretic medication) 40mg (milligrams) IV (intravenous) twice a day, a complete blood count and basic metabolic panel in the AM (morning), to increase the dosage of Potassium to 20 mEq (milliequivalent) twice a day, and to discontinue the ABG (arterial blood gas) order. Record review evidenced the PA failed to document the time they wrote the order.

3. Licensed nurse F on 5/9/10 at 5:55am took a verbal order from the PA to leave off the TED hose (compression stockings) until further evaluation. Record review evidenced when the PA and the physician authenticated the order, they both failed to document the date and time.

The hospital admitted patient #12 on 6/20/09 to the Swing Bed Program. Record review evidenced between 6/20/09 to 6/23/09 multiple practitioners failed to time and date 19 physician order entries when they authenticated the order.

For example:

1. Licensed nursing staff on 6/22/09 at 9:30am obtained a verbal order from the PA for a completed blood count and a basic metabolic panel in the AM. Record review evidenced when physician assistant D and physician G authenticated the order, they both failed to document the date and time.

The hospital admitted patient #13 on 11/28/09 to the Swing Bed Program. Record review evidenced multiple practitioners failed to time and date physician order entries when they authenticated the order.

For example:

1. Licensed nursing staff on 11/28/09 obtained a verbal order for medication changes. Record review evidenced when physician assistant I and physician G authenticated the order, they both failed to document the date and time.

- The hospital's 5/1/03 policy "Medical Record Guideline for Physicians" directed that "...All entries must be timed, dated and authenticated...".

Staff B on 5/10/10 at 2:30pm acknowledged nursing staff, physician assistants and physicians failed to time when they wrote physician orders and the PAs and physicians failed to date and time when they authenticated their orders.

The failure to document the time when writing orders and to document the date and time when authenticating orders also affected patients #14, 15, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 and 31.