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.

NORTHWEST HOSPITAL CENTER 5401 OLD COURT ROAD RANDALLSTOWN, MD 21133 June 14, 2013
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on observations on a medical-surgical unit and an interview with a patient on June 12, 2013, it was determined that medications for two patient were not administered in accordance with the standards of practice. The findings were:

During a tour of the 3D unit at 9:33AM with the Director of Clinical Information Systems and the Director of Inpatient Services it was noted that a medication in a clear pharmacy bag was laying on the charting desk outside the room of patient #41. The medication was an anti-viral agent to be given at bedtime. The label on the bag contained a pharmacy number with a fill date of 06/06/13. The medication was unsecured and not within view of the licensed nursing staff. It could not be determined how long the medication had been there.

The charting desk is a part of a wall mounted patient care system (Freson) which contained a locked drawer for medications, cabinet storage of patient supplies, and a push/pull desk for charting. The pill in its bag was discovered when the surveyor pulled out the charting desk from the wall system.

On 06/12/13 at 9:50AM during the tour of the 3C wing, patient #42 was observed laying in bed in his room. On the patient's bedside table was a clear plastic medicine cup that contained four orange pink pills. The patient was interviewed as to what the medication was and the patient replied, "I think it is my Diovan (anti-hypertensive agent), but I am waiting for the nurse to bring me some water to take them." Approximately eight to ten minutes after the interview, a nurse was observed going into the patient's room.
VIOLATION: CONTENT OF RECORD - DISCHARGE DIAGNOSIS Tag No: A0469
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of 20 closed medical records it was determined that the medical records for three patients were not completed within the 30 day time frame as required by the regulation.

Patient #24 was admitted on [DATE] and discharged on [DATE]. However the discharge summary was not authenticated by the physician's signature until 06/10/13.

Patient #25 was admitted on [DATE] and discharged on [DATE]. The discharge summary was not signed by the physician until 06/12/13.

Patient #27 was admitted on [DATE] and discharged on [DATE]. The discharge summary was not signed by the physician until 06/12/13.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

On June 14, 2013, while touring the hospital's outpatient infusion center, an inspection of the central supply area was completed. On inspection of both clean and sterile patient supplies, it was determined that the cart contained three anaerobic blood cultures bottles (for use in determining the presence of blood stream infections) which had expired on [DATE]. Availability of expired blood culture bottles places patients at risk for inaccurate blood studies.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on Behavioral Health Unit observations, interviews with the Unit Manager, a RN and patient #64 along with review of three open medical records, it is determined that the hospital failed to individualize care planning to include the need for protective footwear for patients #64 and #65, both with diabetes.

On 6/12/2013 at 9:30 am, a brief tour of the unit revealed locked cubbies in patient rooms and no patients wearing shoes. On inquiry, the Unit Manager stated that the unit policy, meant to reduce kicking injuries, was that patients give up their shoes/boots on admission, which are then locked in the cubbies, and that patients are given hospital socks with non-skid soles. Additionally, patients identified as being at risk for falls are given yellow non-slip socks to identify their fall risk.

On inquiry, a RN identified two patients who had diagnoses including diabetes. Observation of these two patients, #64 and #65, revealed that both were wearing only the hospital-provided socks on their feet despite the standard of care which requires protective footwear for patients with diabetes.

Review of the medical records for patients #64 and #65 revealed interdisciplinary care planning and diabetic teaching, but no identification of the need for protective footwear. Additionally, patient #64 stated during an interview on 6/12/13 that he has tingling and numbness of his left foot.

Staff of the behavioral health unit failed to individualize the care plans for two diabetic patients, and failed to accommodate the occasional need for protective footwear in their unit policy regarding removal of shoes from all patients.
VIOLATION: PHARMACY DRUG RECORDS Tag No: A0494
During a Behavioral Health Unit (BHU) tour, an expired emergency drug box was found in a locked treatment room--an area not accessible to patients. Investigation revealed that neither the pharmacy nor behavioral unit staff were aware of the box's presence on the unit, and pharmacy staff did not have a record of how the box got onto the unit, and could not provide a paper trail accounting for the controlled medications present in the box.


During a brief tour of the BHU on 6/12/2013 at 9:30 AM inclusive of the treatment room, revealed a locked box labeled "Rapid Response Box" (RRB) with an expiration date of 5/30/2013. Inquiry regarding the nursing log for the box revealed that the Pharmacy keeps the log for these boxes. Further hospital investigation revealed that the drug box, normally used by the rapid response or code blue teams, had been placed in the behavioral health unit in error earlier in the year when the unit opened. The RRB is the size of a small toll box and contains 34 medications, inclusive of, but not limited to Class II controlled substances in multiple doses, such as morphine and hydromorphone, along with Class III medications including diazepam and midazolam.


The only policy found on handling of the RRB outside of the Pharmacy is the policy "Rapid Response Team/Bat Code" (eff. May 12, 2010) which states:

"RRT (rapid response team) Travel Meds - The ICU (intensive care unit) will serve as base location for the designated travel medication box. The RRT Travel Box will remain in the McKesson medication cabinet and will be accessible as a special inventory item. Once opened, the Travel Box will be returned to the pharmacy by the RRT RN in exchange for a new unopened Travel Box." In practice, since the ICU is the source for staff for the RRT and code teams, the locked boxes are kept in the locked medication cabinet and the individual medications are charged to a single patient once the box is opened, where ever in the hospital the emergency occurs. Opened boxes are to be returned to the pharmacy to be restocked and relocked with a tamper-evident lock.


Pharmacist interview revealed that there are two RRB in the McKesson cabinet in the ICU, but the pharmacist was unable to account for unopened boxes that are removed from the cabinet but not used for a patient.


Based on all information, the Pharmacy failed to track one box containing Class II and Class III controlled medications and could not demonstrate a system to track emergency drug boxes removed from the locked ICU cabinet but not used for a patient emergency. In addition, unit staff on the BHU were unaware that they had a box containing controlled medications in their treatment room.