HospitalInspections.org

30553

Based on observation, review of facility policy, and interview, the facility failed to ensure the disposal of opened medication vials in the off campus physical therapy department, and the labeling of drugs and biologicals on the medical-surgical unit.

The findings included:

Observation on January 7, 2014, at 1:30 p.m., at the facility's off campus physical therapy center, revealed one five milliliter (ml) vial of Dexamethasone Sodium Phosphate (an injectable steroid) 4mg (milligram)/ml, with the plastic cap removed and a puncture mark visible in the rubber septum.

Interview with the physicial therapist, in the medication room, on January 7, 2014, at 1:30 p.m., confirmed the vial had been opened, the vials were "single use", and were to disposed of after opening. Further interview with the therapist confirmed the vials were not used for injections or on more than one patient, and the therapist had failed to dispose of the observed vial after using it on one patient.

Review of the facility's policy number PM03-20, dated January 13, 2011, revealed, "Single use 5 ml vials of dexamethasone sodium phosphate (4 mg/ml) will be emptied of solution and discarded in a biohazard waste container."

Observation on January 7, 2014, at 12:45 p.m., in the medical surgical medication room, revealed one half full quart bottle of green food coloring and one small 5cc (cubic centimeter) full bottle of blue food coloring in the medication storage cabinet. Further observation revealed the quart bottle had no date to determine when the bottle was opened. Continued observation revealed the small 5cc bottle was not labeled and had no date to determine when the bottle was opened or an expiration date on the bottle.

Interview with the Nurse Manager of the Medical Surgical Unit, on January 7, 2014, at 12:50 p.m, in the medication room, confirmed the bottles contained food coloring, was used for patients with tube feedings in the past, and had not been used "...in a long time..." Further interview confirmed the quart bottle did not have an opened date on the container, and the small bottle was unlabeled.