The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on observation, interview, and policy review, the facility failed to ensure medications were secured. In addition, the facility failed to ensure medications were removed from stock prior to their expiration dates. These failed practices created a potential for unauthorized access to medications and created a risk for deterioration of medications, which placed patients at risk for receiving subtherapeutic medication doses. Findings:

Observation on 7/9/12 at 6 pm revealed the operating room, clean utility room, and the supply room, areas where medications are stored, were not secured. An investigation of these areas was conducted from 6:00 pm to 7:30 pm.

Operating room
An unlocked supply cabinet in the operating room contained the following medications, some past their expiration dates:
2 - 20 ml vials of Lidocaine HCL 2% 10 mg/ml 20 Injection;
1 - 10 ml vial of Marcaine 0.5% Bupivacaine HCL Injection;
3 - 30 ml vials of Marcaine 0.25% Bupivacaine HCL Injection (expiration date June 1, 2012); and
1 - 20 ml vial of Xylocaine - MPF Lidocaine HCL and Epi Injection 2% (expiration date 6/12).

An unlocked anesthesia cart in the operating room contained the following expired medications:
2 - Atropine Sulfate 1 mg/ml expiration date May 2012;
1 - 10% Calcium Chloride Injection 1gm 10ml expiration date July 1, 2012; and
2 - Ultane sevoflurane 250 mg inhalation anesthetic expiration date May 5, 2012.

Clean utility room
An unlocked cabinet in the clean utility room, adjacent to the operating room, contained the following medications, some past their expiration dates:
1 - 20 ml of Lidocaine HCL 1% 10 mg/ml;
6 boxes of Revonto 20 mg vials; and
2 - 1 ml vials of Heparin Sodium Injection 10,000 USP units/ml in an opened cabinet; one vial's expiration date was 4/12.

Supply room
Observation in the supply room revealed 2 unsecured entrances; one through the hallway going to the operating room, and one through the hallway across from patient rooms.
There were multiple bags of IV (intravenous) fluids on open shelves.

During a tour of the surgical area and supply room, on 7/10/12 at 9:00 am, the Clinical Services Director, who is responsible for the areas, confirmed the medications were not secured. She stated, "Any staff, patient or family member can come back here." When the Director was asked who checked outdates of the medications, she replied that either she does or the central supply aide does.

During an interview on 7/11/12 at 3:15 pm the Pharmacy RN was asked if she checked for outdated medications in the surgical area. She said she rarely does the operating room, but that was one of her areas. The Pharmacy RN added that usually the Clinical Services Director was responsible for checking for outdates. During the interview the Pharmacy RN confirmed the surgical areas were unsecured.

During an interview, on 7/11/12 at 1:27 pm, the Director of Nursing (DON) was asked about the consultant Pharmacist's scope of responsibility regarding the safety and security of facility medications. The DON replied, "I have no answer to that."

Review of the facility's current contract with the consultant Pharmacist revealed, "The professional services shall include...drug control, safety, storage..."

Review of the facility's "OUTDATED DRUGS" pharmacy policy, dated [DATE], revealed, "...Always check the preceding months outdates to be sure they have been pulled..."

Based on record review and interview the facility failed to ensure medication error was reported for 1 patient (#5) out of 5 sampled patients. This failed practice placed the patient at risk for not receiving prescribed pain medication. Findings:

Record review on 7/9-11/12 revealed Patient #5 was admitted to the facility on [DATE] with diagnoses that included cancer of the lungs and pain associated with the disease. The patient's medication regimen included duragesic (narcotic pain medication, brand name Fentanyl) administered by transdermal patch, to be changed every 3 days.

Review of a nurse's note, dated 3/23/12 at 2300 (11:00 pm) revealed, "Requesting pain med - New Fentanyl patch placed on L [left] arm - Old patch placed on Rt [right] Not found on pt. [patient] or in bed."

During an interview on 7/11/12 at 12:10 pm, LN #1 was asked what would be done if a Fentanyl patch was missing from a patient. LN #1 said the nurse would fill out an incident report and also a medication error report. LN #1 confirmed that neither an incident report nor a medication error report were completed for the Patient's missing Fentanyl patch and added that they should have been done.

During an interview, on 7/11/12 at 1:27 pm, LN #2 was asked about the patient's missing Fentanyl patches. LN #2 said, "It would be easy for people to take it. It may be assumed to have fallen off or be in the laundry. LN #2 was then asked about the facility's process for a missing Fentanyl patch. LN #2 stated, "We would tell the certified nursing assistants to look for it" and added that there "was no process in place to report it."

During an interview on 7/11/12 at 1:27 pm the Director of Nursing was asked if an ordered Fentanyl patch that was not found on the patient or in the bed would be considered a medication error. The Director of Nursing said it would have been a missed dose; a medication error.

Review of the 2012 incident log, provided by the facility, revealed no documented evidence of either a medication error or incident report for Patient #5's missing Fentanyl patch.

Review of the facility's policy and procedure "Medication Error", dated 8/6/01, revealed, "Definition of Medication Error...Omission of the medication..." and "Procedure...complete incident report, complete medication error sheet..."

Review of the facility's policy and procedure "Incident Reports", dated 12/99, revealed, "an incident is any occurrence not consistent with the routine operation of the hospital or the routine care of a particular patient...immediately...means as soon as possible but ought not to exceed 24 hours after discovery of the incident..."