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.

SOUTHEASTERN REGIONAL MEDICAL CENTER 300 W 27 ST PO BOX 1408 LUMBERTON, NC 28359 June 19, 2014
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy and procedure review, medical record reviews, pyxis (medication delivery system) medication report, observation, and staff interviews, the facility staff failed to witness narcotic waste per hospital policy for 1 of 2 medication administration observations ( patient #14).

The findings include:

Review of facility policy section " Q. NARCOTICS/CONTROLLED SUBSTANCES: 2. Computerized System: a. The nurse will: i. Log into the pyxis by entering their appropriate identification information. ii. Select the appropriate patient. iii. Select the appropriate medication. b. Before removing the medication, he/she will verify medication count is correct. Any discrepancies are to be resolved or reported to Pharmacy as an unresolved discrepancy. c. If a partial medication unit is to be given, the amount given and amount destroyed must be validated by a second nurse entering his/her personal identification number. NOTE: The 2nd nurse must actually watch the wasting of medication."

Open medical record on 06/18/2014 of Patient #14 revealed a [AGE] year-old male admitted on [DATE] with diagnosis of pancreatitis (inflammation of pancreas). Review of the medical record revealed a physician's order for IV Dilaudid (Intravenous narcotic medication) every 4 hours as needed for abdominal pain. Medical record review revealed RN #5 administered IV Dilaudid on 6/18/2014 at 1054.

Review of a report from Pyxis (medication dispenser) dated 06/18/2014 revealed RN #6 witnessed wastage of narcotic with RN #5 on 06/18/2014 at 1053.

Observation on 06/18/2014 at 1055 revealed RN #5 wasted unused narcotic in the patient's room sink without the presence of RN #6.

Interview on 06/18/2014 at 1100 with RN #5 revealed "I know I should have wasted it with (RN #6) but I was in a hurry."

Telephone interview on 06/19/2014 at 1505 with RN #6 revealed "I know I should have stayed at the sink and wasted the medicine."

Interview confirmed the nurse failed to witness narcotic waste per hospital policy.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observations during tour and staff interview the hospital failed to maintain safety and quality of medical supplies as evidenced by 3 of 8 expired culture swabs, 2 of 2 expired chloraprep applicators, and 1 of 2 gastrocult developer solution.

The Findings include:

Observation during tour of the 7th Tower Nursing Unit on 06/18/2014 at 1025 revealed the unit was divided into two sides; 7 north and 7 south. Observation during tour of 7 north revealed 4 culture swabs at the nursing unit's medication station. Review of the culture swabs revealed an expiration date of December 2013 on (2) two of the culture swabs (5 months expired).

Observation during tour of the 7 south side of the 7th tower nursing unit revealed 4 culture swabs at the nursing units medication station. Review of (1) one culture swab revealed an expiration date of December 2013. (total of 3 of 8 expired culture swabs).

Continued observation on the 7 south side revealed (2) two Chlora Prep (antimicrobial) Applicators. Review of the (2) applicators revealed expiration dates of January 2013 (1 year and 4 months expired) and March 2013 (1 year and 2 months expired).

Continued observation on the 7 south side revealed (2) Gastrocult Developer (testing for blood in stool) solutions. Review of (1) Gastrocult Developer solution revealed an expiration date of March 2014 (2 months expired).

Interview with Administrative Staff #1 during the tour revealed the supplies were outdated and should have been removed from floor stock. Interview confirmed the hospital failed to maintain safety and quality of medical supplies as evidenced by expired medical supplies.
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of the hospital's policies and procedures, staff interview and review of medical records, the facility failed to provide an Important Message from Medicare form to 3 of 3 sampled patients (#8, #18, and #19).

The Findings Include:

Review of the hospital' policy and follow up process guideline "Care Management Important Message from Medicare (IMM)" (no date), revealed "If the Care Manager has determined that the patient is likely to be discharged within 2 days they will: Go to patient's room and ask if they still have the IMM form. If the patient has their copy, the Care Manager will ask if they have any questions about the form. If the patient has questions, the Care Manager will try to answer their questions. The Care Manager will document that they reviewed the IMM form with the patient in Care Management progress notes. If the patient does not have a copy of the IMM form they were given on admission the Care Manager will: Make a copy of the original IMM form kept under the 'consent' tab in the paper Medical Record. Take the copy of the form to the patient's room; give the copy to the patient; and ask if they have any questions about the information on the form. If the patient has questions, Care Manager will try to answer their questions. The Care Manager will document that the patient did not have the original copy of the IMM form in their room and that they gave and reviewed a copy of the original IMM form with the patient".

1. Closed medical record review on 6/18/2014 of patient #19 revealed a [AGE] year old female admitted on [DATE] at 0146 to the hospital for altered mental status. Medical record review revealed a discharge date of [DATE]. Continued medical record review revealed no IMM letter documentation at admission or discharge.

Interview on 06/19/2014 at 1500 with administrative staff #2 revealed "No IMM message of this chart-admission or discharge. It fell through the cracks."

2. Closed medical record review on 06/19/2014 of patient #18 revealed a [AGE] year-old male admitted on [DATE] at 1113 for a fall with left lower leg pain. Medical record review revealed a discharge date of [DATE]. Continued medical record review revealed an IMM letter dated 06/9/2014 at 0820. Record review revealed no discharge IMM letter documentation.

Interview on 06/18/2014 at 0857 with case manager #1 revealed "this chart only has the admission IMM letter."

3. Closed medical record review on 06/18/2014 of patient #8 revealed a [AGE] year-old female admitted on [DATE] for evaluation after motor vehicle collision. Medical record review revealed a discharge date of [DATE]. Continued medical record review revealed an IMM letter dated 04/29/2012 (no time documented). Record review revealed no discharge IMM letter documentation.

Interview on 06/18/2014 at 0855 with case manager #1 revealed we only give "IMM notes only at admission, not at discharge." Interview revealed the policy has not been followed to follow up with the patient two days prior to discharge with an IMM letter.

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