HospitalInspections.org

The Hospital identified a census of 2 patients. Twenty two (22) patient records were reviewed including both open and closed records. Based on policy review, record review, and staff interview, the Hospital failed to assure staff dated and timed all entries into the medical record for 18 of 22 records reviewed (patient #'s 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 17, 20, 21, and 22).

Findings include:

- The Hospital policy # ADMR.19, reviewed on 3/22/12 documented "Procedure: 1. Each entry in the medical record shall be dated, timed and authenticated by the person making the entry..."

Patient #1's closed medical record reviewed on 3/21/12 revealed an admission date of 2/10/12 for a Right Carpal Tunnel Release, surgical procedure. Patient #1's medical record revealed the history and physical lacked a time when authenticated (signed) by the physician, and one physician progress note lacked the date and time when authenticated.

Patient #3's closed medical record reviewed on 3/21/12 revealed an admission date of 12/12/11 for a Bilateral Myringotomy (an incision made in the ear drum) with tube placement, surgical procedure. Patient#3's medical record revealed one physician procedure note lacked a time when authenticated and one discharge form lacked a time when authenticated by the nurse.

Patient #4's closed medical record reviewed on 3/21/12 revealed an admission date of 11/21/11 for a Total Abdominal Hysterectomy surgical procedure. Patient #4's medical record revealed one physician procedure note lacked a time when authenticated and one operative permit signed by the patient lacked a time when authenticated by the nurse.

Administrative staff A, interviewed on 3/22/12/at 4:00pm, acknowledged the medical records lacked documentation of the time and date on these entries into the medical record.

- Lack of complete authentication of entries in the medical record, which included date and time of all entries also affected the medical records of patient #'s 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 17, 20, 21 and 22.

The Hospital reported a census of two patients. Twenty two (22) patient records were reviewed including open and closed records. Based on observation, policy review, and staff interview the Hospital failed to assure outdated, unusable drugs were not available for patient use in one of one anesthesia medication storage cabinet.

Findings include:

- The Hospital policy titled "Outdated/Unusable Drugs" reviewed on 3/22/12 at 6:05pm directed, "All outdated or unusable medications are to be removed from normal drug distribution and relocated to a designated area in the pharmacy".

- Observation on 3/20/12 at 10:20am of the anesthetist's work area revealed a medication storage cabinet with the following expired drugs:
1. Eight-10milliliter (ml) vials of Brevibloc (a local anesthetic) with an expiration date of 1/12.
2. Four-1ml vials of Hydroxzine Hydrochloride with an expiration date of 8/11.
3. One vial of Sensocaine .75% (a local anesthetic) with an expiration date of 6/11
4. Four-4ml vials of Lasix (a medication to rid the body of excess fluids) 40milligrams (mg) with an expiration date of 3/1/11.
5. One-2ml vial of Lasix 20mg with an expiration date of 8/1/11.
6. One-1ml vial of Epinephrine (an anti-allergy medication) 1:1000 with an expiration date of 2/1/11.
7. One-1ml vial of Epinephrine 1:1000 with an expiration date of 12/1/11.
8. One-1ml vial of Epinephrine 1:1000 with an expiration date of 5/1/11.
9. One-2ml vial of Clindamycin (an antibiotic) with an expiration date of 1/12.
10. Two-1ml vials of Neostigmine 1:1000 with an expiration date of 12/11.
11. One-1ml vial of Naloxone Hydrochloride 0.4mg/ml with an expiration date of 8/1/11.

Staff C interviewed on 3/20/12 at 10:20am acknowledged the anesthetist's medication cabinet contained expired medications.

Administrative staff A interviewed on 3/20/11 at 11:30am acknowledged the Hospital failed to assure outdated and unusable drugs were not available for patient use.

- The Hospital's policy titled "Medication Preparation" reviewed on 3/22/12 at 8:20am dictated, "Multiple Dose Vials (MDV): All MDV's must be dated upon opening and disposed of within 28 days, unless contaminated."

- Observation on 3/20/12 at 10:20am of the anesthetist's work area revealed a medication storage cabinet with the following open vials of medication that lacked a date when opened:
1. One-10ml vial of Lidocaine 2% (a local anesthetic) lacked a date when opened.
2. One-50ml vial of Lidocaine 2% lacked a date when opened.
3. One-50ml vial of Polocaine 2% (a local anesthetic) lacked a date when opened.

Administrative staff A interviewed on 3/20/11 acknowledged the open vials of medication lacked a date when opened and the Hospital policy directs staff to discard open vials of medication within 28 days after opening.