HospitalInspections.org

Based on a review of the hospital's written patient rights, observation of waiting areas throughout the facility, and interview with agency administrative staff, it was determined the hospital did not make available to the patient or to the patient's representative the phone number to the State Agency for filing a grievance. This had the potential to affect all patients within the hospital.

Findings include:

A review of the "Patient Information Guide", which included a copy of the patient's bill of rights, and was given to the patient on admission to the facility, failed to include the State Agency Hotline number to which a grievance could be reported.

A tour of the emergency department and the hospital lobby was conducted 4/27/11 at 8:45 A.M., the State Agency Hotline phone number to which the patient may call with a grievance was not posted.

An interview with Employee Identifier #1, Chief Administrative Officer, on 4/28/11 at 11:00 A.M. verified the phone number was not posted, nor was it given to the patient as part of the admission process.

Based on interviews, review of the facility's policies and procedures, and review of standards of practice, it was determined the facility failed to ensure the pharmacy department filed all the actions taken for recall medications and a process for expired controlled drugs.

Findings include:

Guidance on How to Handle Drug Recall in a Pharmacy:

Recall Procedures for Hospital Pharmacy

All hospital staff is to be notified of the recalled drug.

This information should be immediately entered into the hospital's medication management system as an alert and immediately removed from the hospital's formulary...

Pharmacy staff should inspect all possible storage areas, i.e. stock, patient care areas, medication stations, emergency supplies, patient cassettes, patient storage units within hospital rooms and floor stock.

Depending on the instruction outlined on the recall notice, the recall medication should be disposed of or quarantined in a designated area until further instructions from the FDA (Food and Drug Administration) or manufacturer are received.

The pharmacy should document and file all actions taken to remove the recalled medication.

Referenced from www.ehow.com

A tour of the pharmacy was conducted on 4/27/11 at 10:00 AM with the Employee Identified (EI) # 6, Director of the Pharmacy. The surveyor asked for the process on recalls. EI # 6 stated the recalls were looked at, steps were taken to remove the recalls and then the recall information was thrown away. The surveyor asked EI # 6 how would he know at a later date what steps were taken to remove the recalls. EI # 6 stated there was no record keeping for recalls.

During the tour the surveyor found the following expired schedule II drugs locked up with the current schedule II drugs and were prescribed to a specific patient:

(a). Valium 5 mg per ml in a 30 ml dropper bottle expired on July of 2008.

(b). Diazepam 2 mg with 60 tablets were dispensed and expired on 6/9/10

(c). Ambien 5 mg with 15 tablets dispensed and expired on 5/7/09.

(d). Propoxy Hcl 65 mg 60 tablets dispensed and expired 5/6/09.

(e). Ritalin 10 mg tablets 20 tablets were dispensed and expired 4/14/10.

The following were expired controlled drugs:

(a) Fentanyl patches 5 per box expired on March of 2011.

(b) 48 tablets of Morphine Sulfate Extended Release 15 mg expired on March 2010

(c) 6 suppositories of Morphine Sulfate 20 mg expired on March of 2009.

(d). Methadone 28 10 mg tablets expired on October 2010

(e). 4 Midazolam 10 mg expired on March 2010.

The surveyor asked EI # 6 where the policies were for recalls and disposition of the expired controlled drugs and none could be provided.

Based on observation, interview and review of the hospital's policies and procedures, the facility failed to ensure all medications and supplies available for patient use in the Nursing Station and in the Pharmacy were not expired. This had the potential to affect all patients.

Findings include:

Facility Policy: Control of Out-of-Date Medications

1. Inspection of all stations is made at least once a month.

2. The stations include:
Emergency Room (ER)
Refrigerator in ER and Nurses Station
Regular floor stock
Drug Room
Pharmacy
Labor and Delivery ansethisia cart

Facility Policy: Disposal of Drugs

1. All medications and drugs will be inspected and must be disposed of for any of the following reasons:
(a) Expired expiration date on bottle...

2. Inspections will be made of all stations of the hospital at least once a month. The inspection will be recorded and kept in the hospital pharmacy for reference.

A tour of the Nursing Floor on 4/26/11 at 2:00 PM revealed the following:

1. Room # 315 (labor and delivery)

(a). 8 packages of 1 Compound Benzoin Tincture swabsticks expired in October 2010

(b). 1 ampules of Sodium Chloride 10 ml (militer) expired on April 2010

(c). 1 ampules of Sodium Chloride 10 ml expired on August 2010

(d). 1 bottle of Heparin Lock Flush 10 units/ml 30 ml expired on 1/1/2008

(e). 1 bottle Lidocaine Hcl (hydrochloride) 1.5% 30 ml expired on 8/1/10

(f). 1 bottle Lidocaine Hcl (hydrochloride) 1.5% 30 ml expired on 4/1/11

(g). 3 per package of Povidone Iodine Prep Swabsticks expired July 2008

(h). 1 package of 1 ounce of Iodophor expired on June 2002.

(i). 1 package of 1 ounce of Iodophor expired on March 2005.

(j). 1 package of 1 ounce of Iodophor expired on January 2006.

2. The Drug Room at 2:30 PM

(a). 4 of Tazicef 1 gram expired 4/1/2011

(b). 2 tablets of Clonidine Hcl 0.2 mg (milligrams) with no expiration date

(c). 2 Suppositories of Asprin 600 mg expired August 2010

(d). 3 tablets of Clonidine 0.2 mg expired 11/10

(e). 1 pint bottle of Reme Tussin expired February 2011.

(f). Acetylcysteine 20% (200 mg/ml) 30 ml expired on February 2011.

(g). 3 Promethegan suppositories expired on November 2010.

A tour of the Pharmacy on 4/27/11 at 10:00 AM revealed the following:

1. Controlled Drugs:

The following was locked up with the schedule II drugs and were prescribed to a patient:

(a). Valium 5 mg per ml in a 30 ml dropper bottle expired on July of 2008.

(b). Diazepam 2 mg with 60 tablets were dispensed and expired on 6/9/10

(c). Ambien 5 mg with 15 tablets dispensed and expired on 5/7/09.

(d). Propoxy Hcl 65 mg 60 tablets dispensed and expired 5/6/09.

(e). Ritalin 10 mg tablets 20 tablets were dispensed and expired 4/14/10.

The following were expired controlled drugs:

(a) Fentanyl patches 5 per box expired on March of 2011.

(b) 48 tablets of Morphine Sulfate Extended Release 15 mg expired on March 2010

(c) 6 suppositories of Morphine Sulfate 20 mg expired on March of 2009.

(d). Methadone 28 10 mg tablets expired on October 2010

(e). 4 Midazolam 10 mg expired on March 2010.

2. Stock medications that were not controlled.

(a). 13 Enalapril Maleate 10mg tablets expired 2/1/11

(b). 14 Voltren 75 mg tablets expired July 2010

(c). Vitamin B 1 24 tablets expired October 2010

(d). Zebeta 10 mg 6 tablets expired on January 2011

(e). Dilantin 50 mg 10 tablets expired on 10/9/10.

An interview was conducted on 4/27/11 at 11:40 Am with Employee Identifier # 6, the Pharmacy Director, who verified the pharmacy drugs found were expired.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.

Based on observation, review of the facility's policy and procedures and interview with facility staff, it was determined the facility failed to ensure equipment was monitored to maintain safety of patients and staff. This had the potential to affect all patients receiving physical therapy.

Findings include:

Facility Procedure: Hydrocollator Temperature Procedure

1. Check temp. (temperature) on hydrocolator daily

a. Normal operating temp. is 165 degrees F (Farenheit) but not exceed 180 degrees F.

2. If temp. exceeds 180 degrees F.' then decrease temperature...Repeat check and re-check every 20 minutes, adjusting temp as needed until the temp falls below 180 degrees F.

A tour of the physical therapy department was conducted on 4/28/11 at 7:40 AM. An operable Hydro collator was observed with packs present. The surveyor requested the temperature monitoring logs and the current temperature of the contents. There were no temperature monitoring logs available for review and Employee Identifier # 1, the Chief Administrative Officer stated there was no documentation of a temperature monitoring log.

Based on record review, review of the facility's policies and procedures and interview, it was determined the hospital failed to assure there was an activity program available for 2 of 2 swing bed patients. This affected Medical Record (MR) #9 and #10.

Findings include:

Facility Policy: Activities

Purpose:

To promote maintenance or enhancement of each resident's quality of life.

Policy:

It is the policy of ( name of the facility) to provide an ongoing program of activities based on a comprehensive assessment. The goals of the activities are designed to meet the physical, mental, and psychosocial well being of each patient.

Procedure:

Activities are planned to meet the needs and interest of the patient, both men and women.

1. MR # 9 was admitted to the swing bed unit on 10/04/10 with diagnoses including Congestive Heart Failure. There was no documentation in the medical record to show any activities that had been planned for this patient according to the comprehensive assessment.

2. MR # 10 was admitted to the swing bed unit on 4/15/11 with diagnoses including Right Knee Replacement. There was no documentation in the medical record to show any activities that had been planned for this patient according to the comprehensive assessment.

An interview was conducted on 4/28/11 at 8:30 AM with Employee Identifier # 1, the Chief Administrative Officer who verified the above.