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 and staff interviews the facility failed to prevent unmonitored access of medications by unauthorized individuals. Drugs and biologicals must not be stored in areas that are readily accessible to unauthorized persons.

The findings include:

1. A tour of 6 North on 05/18/2011 at 9:50am revealed there to be an unlocked medication cart in the public hallway with medication on top of the cart placed in a notebook between the pages. The cart was unattended and no staff was in proximity of the cart. All drawers were able to be opened. There were 2 open vials of insulin noted to be in one of the drawers labeled "0.5 insulin syringe and 1 cc insulin syringe". One vial was Novolog 10ml multi dose vial (MDV) 100 unit/ml vial open and dated 06/02/2011 for discard. The other vial was Humulin R 10ml MDV dated to be discarded on 06/02/2011. There were no initials to indicate who opened the vials or what date the vials were opened on. Insulin syringes with needles were also located in the drawer. The medication on top of the cart was Zosyn 3.375 grams attached to a 50ml bag of normal saline (NS). It had not been mixed into the bag.

2. An interview with the risk manager (RM) on 05/18/2011 at 9:55am revealed that it is the facility's policy to always lock medication carts when in the public corridors.

3. An interview with 6 North unit manager on 05/18/2011 at 9:58am revealed that she agreed that all medication carts should be locked when not in attendance and expressed concern that this one was not. She stated that the nurse was a new nurse but that just yesterday all nurses had been reminded to lock their carts.

4. A tour of 8 North on 05/18/2011 at 12:05pm revealed another unlocked and unattended medication cart. A drawer labeled 5b had 2 medications sealed in plastic and foil. The 2 medications were lisinopril 2.5mg and carvediol 3.125mg both in pill format. Drawer #16 had Mupiricin 2% ointment tube located within. Another open drawer contained an opened insulin Novolog 10ml MDV and had a label that stated to discard on 6/20/11. In consideration that the observation was conducted on 5/18/2011 that would indicate the vial would not be discarded until 33 days in use.

5. An interview with the RM on 05/18/11 at 12:10pm revealed that it is the policy of the facility to discard all opened MVDs 28 days after opening. She expressed concern with the findings and could not explain why vials are being dated before they are opened and/or dated beyond the 28 days. She also reiterated that it was the policy to lock all medications.

6. An interview with the pharmacist on 05/18/11 at 12:20pm revealed that all MDVs including insulins are to be discarded 28 days after opening. She was unable to explain why the date on the vial was 33 days before it was to be discarded. She stated that the labels that state what date to discard the MDVs are placed on the vials in the pharmacy and that vial is hand dated by pharmacy when it is sent to the units. She was unable to explain why a vial would be dated beyond the 28 day policy or how the date was affected if the vial was not opened for any number of days after it was sent to the unit.

7. Observation of the medication refrigerator on 5/18/11 revealed there to be 3 unopened insulin MDVs that had the date 6/2/11 as the discard date.

8. Interview with the charge nurse on 05/18/11 for 6 Pavilion at 3:45pm revealed that when they receive the insulin vials they are already dated. She stated that if they are not opened that day but later then the nurse should redate it to comply with the 28 days discard policy.

Correction Date: 9/18/11