HospitalInspections.org

Based on review of records and interviews with hospital staff, the hospital does not ensure that current and accurate records are maintained of the receipt and disposition of all scheduled drugs in accordance with Federal and State laws. The drug room does not maintain records of scheduled drugs with sufficient detail to follow their flow from their entry into the hospital through dispensation and administration or wastage in a readily retrievable manner. The hospital does not ensure that the records are in order and all scheduled drugs are maintained and reconciled.

Findings:

1. The drug room does not maintain narcotic administration records of scheduled medications dispensed to the hospital areas that document the following: 1. date 2. patient 3. person administering the drug 4. the physician 5. the dose of the drug and 6. wastage, if any with the person who wasted and witnessed the wastage.

2. Drug room personnel on 08/31/10 in the afternoon stated that they did not know how to retrieve the information from the automatic dispensing machines that contained the required information. They were unable to provide the information for scheduled drugs that contained the above information.

Based on review of the infection control documents, hospital meeting minutes, policies and procedures and personnel files, and interviews with staff, the hospital failed to develop an active infection control program for identifying and preventing infections and communicable diseases.

Findings:

1. The hospital's infection control plan appropriately required surveillance, monitoring and evaluation of all aseptic, isolation and sanitation procedures, including sterilization and disinfection practices, with reporting and analysis of findings.

Review of meeting minutes for infection control, medical staff and quality did not contain data from active surveillance of staff. On the morning of 08/31/2010, Staff B stated surveillance/observation activities of staff to ensure policies and procedures were followed had not been part of the infection control reporting. Staff B stated she had not inserviced employees on proper handwashing/hand cleansing techniques or documented any hand sanitation surveillance.

2. Staff B stated on 08/31/2010 at 1130 that the hosptial "flashed" surgical eye instrument sets between cases. She stated the eye surgeon brought two sets of eye instruments. She stated the instruments were cleaned and sterilized unwrapped for 15 minutes with no dry time between cases and then taken to the operting room.

Review of meeting minutes for infection control, medical staff and quality did not contain data concerning the use of "flash" sterilization with evaluation and plan to limit the use of "flash" sterilization. On the morning of 08/31/2010, Staff B stated the sterilization process had not been part of the infection control program.