HospitalInspections.org

Based on observation, review of facility policy, and interview, the facility failed to remove home medications from bedside for one (#4) of six in- patients reviewed; failed to secure an anesthetic agent in two of two operating rooms; and failed to discard blood collection tubes prior expiration on three of three blood collection trays on the medical/surgical patient care area.

The findings included:


Observation of the medical/surgical unit on June 6, 2011, at 10:30 a.m., revealed seven in-patients. Observation of the room of patient #4 on June 6, 2011, at 10:50 a.m., revealed the patient asleep in bed and a sitter at bedside. Observation revealed a bottle of Nystatin Powder (antifungal/antibiotic) 15 grams (100,000 units per gram) ? full; and a bottle of Nystatin Suspension 240 milliliters (ml) (100, 000 units/ml) ? full on the over-bed table. Review of the bottles revealed they were labeled from a local pharmacy and for use while at the home residence.

Medical record reviews revealed the medications were not included in the ordered medications to be administered while in the hospital.

Review of the facility policy #PHA043 titled Medication Dispensing, revealed, "F. Medications brought to the hospital with the patient should be sent home with a family member...(Or) picked up by a nurse and brought to the pharmacy...G. No medications will be left at the patient's bedside."

Interview with the Director of the Medical/Surgical unit at the nurses' station on June 6, 2011, at 11:35 a.m., confirmed the facility failed to remove the home medications from bedside.

Observation of the surgical services area on June 6, 2011, at 2:30 p.m., revealed two operating rooms (OR). Observation of the top drawer of the unlocked anesthesia machine in OR #2 at 2:32 p.m., revealed a 250 milliliter bottle of Sevoflurane (inhalant used in general anesthesia) ? full.

Interview with the Director of Surgery in OR #2 on June 6, 2011, at 2:35 p.m., confirmed the facility failed to secure the anesthetic agent.

Observation of the top drawer of the unlocked anesthesia machine in OR #1 at 2:36 p.m., revealed a 250 milliliter bottle of Sevoflurane inhalant ? full. Interview with the Director of Surgery in OR #1 on June 6, 2011, at 2:37 p.m., confirmed the facility failed to secure the anesthetic agent.


Observation of the medical/surgical unit (the only in-patient care area in the facility) on June 6, 2011, at 12:32 p.m., revealed three trays at the supply cabinet containing blood collection tubes and supplies. Observation of tray #1 revealed five of five blood culture collection tubes expired on May 31, 2011; observation of tray #2 revealed five of five blood culture collection tubes expired on May 31, 2011; and observation of tray #3 revealed four of four blood culture collection tubes expired on May 31, 2011.

Interview with the Director of the Medical/Surgical unit at the nurses' station on June 6, 2011, at 11:35 a.m., verified the nurses are responsible for the collection of blood cultures; and confirmed the facility failed to remove the expired blood collection tubes.

Based on observation, review of facility policy, and interview, the facility failed to ensure staff did not have food in work area in two of two operating rooms.


The findings included:


Observation of the surgical services area on June 6, 2011, at 2:30 p.m., revealed two operating rooms (OR). Observation of the top drawer of the anesthesia machine in OR #2 at 2:32 p.m., revealed an individually wrapped chocolate piece of candy.

Review of the (un-numbered) facility policy titled Blood and Body Fluid Exposure Plan, revealed, "In work areas where there is a foreseeable exposure to blood or other potentially infectious material, employees are not to eat, drink ..."

Interview with the Director of Surgery in OR #2 on June 6, 2011, at 2:35 p.m., verified the operating room is an area of high risk of exposure, and confirmed the facility failed to ensure the staff did not have food in the work area.

Observation of the top drawer of the unlocked anesthesia machine in OR #1 at 2:36 p.m., revealed an individually wrapped chocolate piece of candy and a ? ounce package of peanut butter.

Interview with the Director of Surgery in OR #1 on June 6, 2011, at 2:37 p.m., confirmed the facility failed to ensure the staff did not have food in the work area.