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A. Based on a review of Hospital policy and procedure, a review of the Pyxis controlled substance error logs, and staff interview, it was determined that the Hospital failed to ensure all errors involving controlled medications were properly investigated.

Findings include:

1. The Hospital policy and procedure titled, "Medication Administration: Automated Dispensing Machine (ADM)" was reviewed on 10/10/09. It indicated under, "Procedure: Discrepancy Resolution and Reporting...All discrepancies are to be resolved at the time of discovery....Reasons for discrepancies must be documented, monitored, and addressed if inappropriate...."

2. The Pharmacy controlled medication error reports were reviewed of Nov/Dec of 2009. Documentation on numerous discrepancies (such as the one dated 11/30/09 at 01:15) were simply corrected by entering "entered wrong amount when inventoried drawer". However, it was noted that the counts were off by as many as 5 to 7 items. There was no documentation of any further investigation as to the loss of the controlled medications.

3. During interviews the the Pharmacy Manager and a Pharmacy Tech, conducted on 12/10/09 at 10:15 AM, it was verbalized that if a Pharmacy Tech goes to resolve a controlled medication discrepancy, usually the nursing staff are just asked what happened. There is seldom an investigation to review documentation that would indicate that the medication was administered and documented on the medication administration record (MAR). The Pharmacist could not answer questions related to the resolution of the controlled substances and verbalized that there needs to be a more thorough investigation of the controlled medication discrepancies. He confirmed the above findings.

A. Based on a review of Hospital policy and procedure, review of Dietary's 3-Compartment Sink/Sanitizer Log, and staff interview, it was determined that the Hospital failed to ensure the sanitizing water was always checked in a timely manner.

Findings include:

1. The Hospital policy and procedure titled, "Sanitizer Solution Procedure" was reviewed on 12/9/09. It indicated under, "Policy To provide directions for ensuring that solutions used for sanitation are of appropriate strength to sanitize the equipment it is used on." And under, "Procedure 6. Replace the water often as necessary, at least three times per day."

2. The 3-Compartment Sink/Sanitized Logs for the months of Aug, Sept, Oct, and Nov 2009 were reviewed. There was no documentation that indicated the water was properly tested in Aug 54 of 93 times; Sept 52 of 90 times; Oct 59 of 93 times; and Nov 53 of 90 times.

3. During an interview with the Dietary Manager, conducted on 12/10/09 at 10:45 AM, it was verbalized that the sanitizing solutions should be checked at least 3 times a day. She confirmed the above findings.

B. Based on a review of Hospital policy and procedure, observation, and staff interview, it was determined that the Hospital failed to ensure it's dry goods were dated so "first in, first out" was being used to ensure proper rotation of the dry goods.

Findings include:

1. The Hospital policy and procedure titled, "Storage" was reviewed on 12/9/09. It indicated under "Procedure 1. Each food/non-food item will (be) dated upon receipt. Individual cans or bags will be dated to ensure that the stock is rotated properly."

2. During a tour of the Dietary dry good storage room, conducted on 12/9/09 at 11:30 AM, it was observed that those food/non-food items stored on the flat shelves were not labeled with the date of receipt so as to ensure proper stock rotation.

3. During an interview with the Dietary Manager, conducted on 12/9/09 at 11:45 AM, the above findings were confirmed.

A. Based on clinical record review and staff interview, it was determined that the Nursing staff failed to ensure all patient care assignments were completed as ordered by the physician. This was evident in 1 (Pt. #18) of 20 clinical records completed.

Findings include:

1. Pt. #18 was admitted to the Hospital on 07/20/09 with the diagnoses of sternal wound, shortness of breath, fever and hypertension. The physician ordered daily weights on 07/20/09 and there was no documentation to indicate any weights were obtained.

2. The above findings were verified with the Chief Nursing Officer and Quality manager on 12/10/09 at 10:00 am.

A. Based on a review of Hospital policy, clinical record review and staff interview, it was determined the Hospital staff failed to ensure all verbal orders were timed, dated and authenticated in a timely manner. This was evident in 1 of 20 (Pt.# 16) clinical records reviewed.

Findings include:

1. Hospital policy #PC 3.230 indicates,"All telephone orders must be signed, dated and timed by the physician within 48 hours and verbal orders must be signed, dated and timed by the physician prior to leaving department..."

2. Pt. #16 was admitted to the Hospital on 09/23/09 with the diagnoses of left foot pain, nausea, vomiting and anemia. Verbal orders were written on 09/22/09, 09/23/09 and 09/25/09 for bowel preparation, colonoscopy and medications. There was no documentation to indicate the verbal orders had been dated, timed or authenticated by the physician as of survey date 12/10/09.

3. The above findings were verified with the Chief Nursing Officer and Quality Manager on 12/10/09 at 10:00 am.

B. Based on a review of Hospital policy and procedure, medical record review, and staff interview, it was determined that in 3 of 20 (Pts #6, # 11, and #12) medical records reviewed, the Hospital failed to ensure there were physician orders for all medications/diagnostic tests and that all medications were administered as ordered.

Findings include:

1. The Hospital policy and procedure titled, "Physician's Orders, Transcription Of" was reviewed on 12/10/09. It indicated under, "POLICY 2. ...and verbal orders must be singed, dated and timed by physician prior to leaving department...". And under "OUTCOME: The patient will receive all diagnostic tests, medical treatments, and medications in a timely manner as ordered."

2. The medical record of Pt #6 was reviewed on 12/9/09. It indicated that Pt #6 was admitted on 11/29/09 with a diagnosis of GI Bleed. Documentation indicated that a physician's order, dated 11/19/0 at 8:45 AM was "Give 45 min prior to exam: Atropine 0.4mg IM on call" and "Start IV 1000 D5LR, infuse 300cc of fluid before procedure." There was no documentation that indicated the Atropine or bolus of D5LR was administered as ordered.

3. The medical record of Pt #11 was reviewed on 12/9/09. It indicated Pt #11 was admitted on 12/3/09 with a diagnosis of Chest Pain. Documentation indicated that Pt #11 was administered ASA PO and Nitro sublingual and had the following diagnostic tests: CBC, CMP, and Tronopin. There was no documentation that indicated a physician's order was written for the above.

4. The medical record of Pt #12 was reviewed on 12/9/09 It indicated Pt #12 was admitted on 11/1/09 with a diagnosis of Overdose. Documentation indicated that the following diagnostic tests were performed: CMP, CBC, and Serum Pregnancy. There was no documentation of physician's orders for the tests.

5. During an interview with the Quality Manager, conducted on 12/9/09 at 2:45 PM, the above findings were confirmed.

A. Based on a review of the Medical Staff Rules and Regulations, interview with Hospital staff and a written statement of the Hospital's delinquent medical record rate, it was determined that the Hospital failed to ensure all medical records were completed in a prompt manner.

Findings include:

1. Medical Staff Rules and Regulations indicated on page 47 that all records must be completed within thirty days post discharge. A medical record will be considered delinquent if not completed within 30 days post discharge.

2. On 12/10/09 the Medical Records Director presented a written statement indicating that as of this date there were 31 delinquent medical records.

3. The above findings were verified with the Chief Nursing Officer and Quality Manager on 12/10/09 at 10:00 am.