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LONG ISLAND JEWISH MEDICAL CENTER 270 - 05 76TH AVENUE NEW HYDE PARK, NY 11040 March 8, 2017
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
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Based on observation, document review, and interview, the Emergency Department (ED) Staff failed to follow the Policies for (A) the secured storage of needles and sharps in Patient Treatment Areas, in five (5) of six (6) observations, and (B) the secure storage of medication received from the Pharmacy, in 1 (one) of 1 (one) observation.

This may have placed patients at increased risk for injury or adverse outcomes.

* Findings for A:

The facility's Policy and Procedure titled "Sharps Safety Devices" last revised 01/16 contained the following statement: "Sharps products, e.g., needles, syringes with needles, are to be locked or maintained in a secured manner, e.g., under staff control, in locked cabinets, drawers."

Observations in the facility's Adult ED during a tour between 10:00AM and 11:45AM on 03/06/17 identified the following:

At 10:40AM outside Room #8 a suture supply cart containing suture needles, staple removal kits, and a syringe was observed unlocked.

At 10:45AM outside Room #13 an IV / Phlebotomy supply cart containing Phlebotomy needles, Angio catheters, and other supplies was observed unlocked.

Similar findings were observed for carts located outside Room #16 and outside Room #26.

These observations were made in the presence of Staff Members G, R, and A who confirmed the findings.

During an interview with Staff G and Staff R at the time of these observations, they acknowledged that the carts should have been locked.

During observations of the facility's Pediatric ED on 03/06/17 at 2:00PM, a suture supply cart containing suture needles and supplies was observed unlocked in the "Rapid Access" area.

This observation was made in the presence of Staff T and Staff K who confirmed the findings.

* Findings for B:

The facility's Policy and Procedure titled "Storage and Accessibility of Medication" last revised 02/17 stated the following: "All medications must be stored in an area that can be locked and/or is inaccessible to patients and visitors ... Medications must be placed in approved storage areas upon receipt on nursing units [lockable medication carts/wall cabinets or medication room] ...All medications removed from storage must remain secure at all times and must not be left unattended ..."

Observations in the facility's ED on 03/07/17 at 3:10PM identified an unsecured and unattended medication at the Nursing Station. The administration kit for Lupron Depot 11.25mg, contained a pre-filled medication syringe and needle. The medication was labeled with the patient's name, location, and warning label which stated "Caution: Hazardous Drug, observe special handling, administration and disposal requirements."

Per interview with Staff F on 03/07/17 at 3:17PM, the medication should not have been left unsecured at the Nursing Station. Staff F stated the expectation is for staff who receive medications [from the Pharmacy] to "hand-deliver" medications to the intended recipients or "secure" medications in their medication storage carts. This was confirmed with Staff R.