HospitalInspections.org

Based on observation, interview and document review, the facility failed to properly label cooked food.

Findings include:

On 12/7/11, a tour of the kitchen revealed multiple unlabeled plastic containers in the refrigerator. Plastic bags of sliced luncheon meats (ham, turkey and roast beef) were dated 11/20/11. The label documented the meat expired on 12/20/11. The opened meat should have been discarded on 11/30/11.

An opened container of buttermilk with the manufacturer's use by 11/25/11 was in the walk-in refrigerator.

Food Cooling Policy, revised 7/28/08 documented all chilled products must be labeled, wrapped, and dated to ensure the product was used according to FIFO.

Safe storage of leftover food policy, reviewed August 2009 documented containers with leftovers will be labeled with food/product name and date the food/product was originally served.

Based on interview, record review, and policy review, the facility failed to take timely corrective action following the recommendation of the qualified radiation physicist.

Findings include:

On 12/8/11, Employee #23 confirmed that the facility did not address the recommendation from the radiation physicist's report, dated 4/9/11, that the Y Collimator readout on the portable diagnostic X-ray device, GE model 46-27061P2, serial number 986150WK1, needed service adjustment.

Based on observation, interview and document review, the facility's nurses failed to follow its policies regarding medication administration, documentation, and secure storage.

Findings include:

Patient #3

On 12/4/11, Patient #3 was admitted for an emergency appendectomy and discharged on 12/8/11.

Postoperative orders included Hydromorphone 0.5-2 milligrams intravenously as needed for pain every 2 hours.

On 12/6/11, the medication administration record showed a nurse administered Hydromorphone 1 milligram at 7:30 AM and again at 10:00 AM.

On 12/9/11, Employee #14 provided the all station events report for Patient #3's stay.

The report showed a nurse did not waste Hydromorphone 1 milligram at 7:30 AM and Hydromorphone 1 milligram at 10:00 AM. The report showed a nurse did not withdraw a vial of Hydromorphone for the 10:00 AM administration. The entire report was checked for Hydromorphone usage against the documentation of usage on the medication administration record. All the other Hydromorphone usage was reconciled.

Employee #14 agreed the nurse administered the 7:30 AM and 10:00 AM doses from the same vial removed from the drug machine at 7:31 AM on 12/6/11.

The facility's policy #RX-001, Administration of Drugs last reviewed 1/2011, indicated "...Authorized staff members administering medication should not carry medications on their person ...Medications retrieved for patient use but not given shall be returned to the Pyxis..."

Employee #14 added a written addendum on site to policy #RX-086 as a result: "revise policy to reflect any vial may not be punctured more than once. Once a vial is entered, it must be discarded or wasted."

The facility's policy #RX15-07, Controlled Substances, Accountability of Waste last reviewed 1/2011, "...VII. Waste of partial doses in patient care areas ... must be witnessed and documented by signature of two licensed personnel. This waste must be destroyed in compliance with EPA [Environmental Protection Agency] and state regulations and placed in the pre-determined, drug-specific waste stream..."

On 12/7/11, the medication administration record showed a nurse administered Hydromorphone at 7:00 AM and again at 11:00 AM. In both instances, the record lacked documentation of the dose the nurse administered.

The all station events report for Patient #3's stay showed the nurse administered 1 milligram and wasted 1 milligram for the 7:00 AM and 11:00 AM administrations.

Patient #5

On 12/8/11, Patient #5 was admitted for outpatient surgery for a right bunionectomy and hammertoe correction.

On 12/8/11 at 12:28 PM, personnel removed Patient #5, and all staff members left the operating suite.

The certified nurse anesthetist left the operating suite with the anesthesia cart unlocked and two medications atop the cart, a half full vial of 1 milligram per milliliter of Glycopyrrolate and a syringe with 5 milliliters of 20 milligrams per milliliter of Succinylcholine, were left out in full view. Between 12:28 PM and 12:36 PM, a surgical technician entered the suite alone for turning the suite over followed by a housekeeper. Both employees were in the suite alone at times as well as the surveyor.

On 12/9/11 at 2:50 PM, Employee #2 and Employee #14 indicated medication should not be left out unsecured on an anesthesia cart.

The facility's document entitled Position Description/Competency Based Evaluation contained a list of general duties for certified registered nurse anesthetists, including "...10. Maintains anesthesia drugs in locked cart when unattended..."

The facility's policy # RX-001, entitled Administration of Drugs (General) last reviewed 1/2011, indicated "...When not in use, medications are to be securely stored in Pyxis Med station 4000 or a lockable medication area..."