HospitalInspections.org

Based on review of Medical Staff Rules & Regulations, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure that all orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or another practitioner who was responsible for the care of the patient in 12 of 45 medical records reviewed (MR7, MR17, MR18, MR19, MR32, MR33, MR34, MR35, MR36, MR37, MR40, and MR41).

Findings include:

A review on October 14, 2011, of "Administrative Policies and Procedures, Orders for Medication or Treatment of a Patient, revised July 2011," revealed, "...6. A practitioner must sign, date and time all verbal and telephone orders within 24 hours..."

1) A review of MR7, MR17, MR18, MR19, MR32, MR33, MR34, MR35, MR36, MR37, MR40, and MR41 revealed verbal orders that were not signed, dated and/or timed.


An interview conducted on October 14, 2011, with EMP2, confirmed that the medical records contained verbal orders that were not signed, dated and/or timed.

Based on observation and interview with staff (EMP), it was determined the facility failed to ensure outdated medications and supplies were removed from service.

Findings include:

1) Observation on October 12, 2011, of the anteroom/overflow room located in the Emergency Department revealed the following outdated medications: three peel packs (each containing ten tablets) of Acetaminophen (a pain reliever) that had expired in July 2011; one individual dose container of oral Acetaminophen elixir that had expired May 2011; and five individual dose containers of pediatric Ibuprofen elixir (a pain reliever) that had expired May 2011.

An interview conducted on October 12, 2011, at 10:00 AM, with EMP1, confirmed that the Acetaminophen and Ibuprofen had expired.

2) Observation on October 12, 2011, of the medication room located in the Emergency Department revealed the following: a box labeled "Dental" that contained three boxes of Drypack (used to pack dry wisdom tooth sockets) that had expired in July 2010 and August 2011; two tubes of Drycal (used as a protective base/liner under dental filling materials) that expired May 2010; and a tube of periodontal dressing material that appeared to have been breached with medication leaking out of the seams of the tube.

An interview conducted on October 12, 2011, at 10:30 AM with EMP1 confirmed that the Drypack and Dycal had expired. Further interview with EMP1 confirmed that the tube of periodontal dressing material appeared to have been breached and that medication was leaking from the seams of the tube.

3) Observation on October 12, 2011, of the medication room, located in the Emergency Department revealed a box labeled "Mediport Insertion" that contained several vacutainer tubes (used to collect blood) that were expired.

An interview conducted on October 12, 2011, at 10:30 AM with EMP1 confirmed that the vacutainer tubes had expired.