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 document review, observation and interview, the Nursing Department did not ensure that nourishments and medication (antacid) were properly labeled with the date opened and the discard date as required.

There was a potential that the drug and/or food supplement may lose its efficacy and potentially be unsafe.


During a tour of 3 North on 07/20/16 at 11:30AM, an open unlabeled bottle of Pro-Stat (protein drink) was found in the Medication Room. A review of the Pro-Stat label stated to discard three (3) months after opening.

A bottle of Mintox Antacid was found on the same shelf in the Medication Room. This bottle had a label that documented that it was opened on "7/13" and it was initialed. However, the discard date was blank.

During a tour of Floor GP2 (Telemetry) on 07/20/16 at 2:00PM an open unlabeled bottle of Mintox Antacid was found in the Medication Room. There was neither an open date nor a discard date on the bottle.

A review of the Department of Nursing Education "RN Orientation Workbook" last revised on 12/2014 documents a question and answer format. The question is posed: Does anyone check for outdated floor stock medications? The Response is "Yes", the Nurse Manager is responsible for day-to-day medication checks.

The facility's Policy and Procedure titled Food-Storage of Food on Patient Care Units last revised 10/2015 documented that "All expired food items including p.o. (by mouth) supplements and tube feedings, shall be immediately discarded. Note: Once Pro-Stat is opened on the Nursing Unit, Nursing Personnel must label the container with the date it was opened and discard after 90 (ninety) days."

During an interview with Staff M, Nurse Manager, on 07/20/16 at 11:30AM, the staff member stated that she agreed that both the bottle of the protein supplement and the bottle of antacid should be labeled with both the date the bottle was opened and the discard date. A green label should be affixed to the bottle with the date opened, discard date and initials.
Based on document review and interview, the Pharmacist did not dispense medication in a form that ensured that the patient would receive the correct dose.

This failure places all patients at risk for not receiving medication as prescribed.


Patient #9's Medical Record review identified that on 04/06/16 a Physician ordered 50mg of Carbamazapine (seizure medication) to be give two (2) times a day.

Review of the Medication Administration Record revealed that 50mg was equal to .25 (1/4) of the tablet dispensed.

Per interview with Staff M, Assistant Director of Pharmacy, on 07/25/16 at 1:35PM, the staff member stated that the Nurses on the Unit were responsible to split the pills to achieve the required dose. He also stated the facility Pharmacy only carries two (2) forms of Carbamazapine, a liquid dose of 100mg/5ml, and a pill form of 200mg.

When asked if the pill could be split into four (4) pieces, he replied "No, it shouldn't".

When asked how the medication should have been dispensed, he stated that it should have been sent in a liquid form to ensure the accuracy of the dose.

He also stated "Someone should have been looking at it, it was a slip."

This was confirmed in the presence of Staff N, Director of Pharmacy, who agreed with Staff M.
Based on Medical Record review, document review and interview, the Director of Pharmacy failed to implement a plan of correction for an identified medication dispensing error.

Failure to implement plans of correction for identified issues places all patients at risk for the issue of concern to reoccur.


On 04/26/16 the facility received a complaint from a discharged patient regarding a discharge prescription that was sent to the patient's community Pharmacy electronically.

The complaint alleged that the prescriber ordered a 200mg tablet of Carbamazapine to be given as 50mg, two (2) times a day. The complainant was concerned about cutting the tablet into four (4) pieces.

A facility review of the allegation identified an issue with the formulation of the dosage prescribed.

It was noted in the facility report that the error occurred because the electronic system for prescriptions only offered two (2) selections of medication formulation available to the prescriber, one (1) liquid form of 100mg/1ml and one (1) pill form of 200mg. The prescriber therefore selected the pill form.

On 05/06/16 Staff M, Assistant Director of Pharmacy, was notified by Staff O, Department of Patient Safety, Quality and Innovations, of the issue and potential for a medication error.

Per interview with Staff B, Director of Regulatory Affairs, on 07/25/16 at 2:00PM, no further action was taken by the facility Pharmacy.

The facility's Policy and Procedure titled "Medication Error Reporting and Analysis" last revised 07/2014 states that when an actual or potential medication error occurs, it instructs staff to complete an Incident Report and "All errors are monitored and trended."

The facility lacked evidence by the Pharmacy of any Incident Report, follow-up or correction of the electronic prescription program to offer additional choices to the prescriber to prevent prescription dispensing errors.

The facility also lacked evidence of any reporting of the issue to Pharmacy Quality Assurance / Performance Improvement (QAPI) or the facility-wide QAPI.

Based on record review and interview, the facility did not ensure timely triage of walk-in Emergency Department (ED) patients after check-in, for five (5) of ten (10) ED Medical Records reviewed, nor did they establish a mechanism to address these delays.

These delays place patients at risk for deterioration in their condition prior to triage or receiving a medical evaluation.


Review of the Medical Record for Patient #17 documented that the patient (MDS) dated [DATE] at 11:31AM with a complaint of a Urinary Tract Infection. Triage was documented at 12:26PM, fifty-five (55) minutes later as an ESI (Emergency Severity Index) Level 3 (three).

Review of the Medical Record for Patient #12 documents that the patient (MDS) dated [DATE] at 12:12PM with complaints of throat and left shoulder pain. Triage was documented at 1:02PM, fifty (50) minutes later as an ESI Level 4 (four).

Review of the Medical Record for Patient #16 documents that the patient (MDS) dated [DATE] at 11:47AM with a complaint of left eye pain. Triage was documented at 1:10PM, one (1) hour and twenty-three (23) minutes later as an ESI Level 4 (four).

Review of the Medical Records for Patient #13 and Patient #18 documented similar delays of approximately twenty-five (25) to thirty (30) minutes.

The facility's Policy and Procedure titled "ED Registration Process" last revised 06/27/14 states the following: When a patient presents to the ED as a walk in he/she will check in with the Registrar utilizing the patient's name and date of birth. The Registrar will complete the check in process, obtain the patient's complaint and place the patient in the Waiting (Reception) Area. The patient will be triaged and the acuity of the patient will be determined.

The facility's Policy and Procedure titled " Triage Process in the ED" last revised 06/25/14 states that "Every patient who arrives at the ED either by ambulation, wheel chair or ambulance will be directed to the Triage RN (Registered Nurse), who will complete the Electronic Triage Form and designate an ESI Level for the patient. The Triage RN will then either direct the patient to an assigned stretcher in the Clinical Area or to a seat in the Reception Area but the Policy does not include a process to follow when multiple patients present simultaneously and are waiting to be triaged.

The facility's "Principles of Triage and ESI 5 Level Triage System" course materials dated 2016 document that the Triage Nurse assigns an ESI (Emergency Severity Index) Level to each patient. The determination of Levels 3 and 4 is based on the number of resources (i.e. Laboratory, Radiology) and does not require immediate intervention. The course documents that the Triage Nurse is responsible to monitor the Waiting Room, and when multiple patients present to triage, to prioritize according to stated complaint and general appearance (of the patient). The course material also states "Call for help PRN (as needed)", but does not include specific guidelines.

Per interview with Staff I, Nurse Manager of Clinical Operations for the ED, on 07/21/16 at 10:00AM, the Flow Coordinator RN will monitor the Tracking Board, open another Triage Room and send an additional RN to triage patients, but they are not tracking or reporting on the check-in to triage times.

Per interview with Staff L, ED Medical Director, on 07/21/16 at 11:30AM, they are not currently collecting data or reporting on the time between check-in and triage.
Based on interview and document review, the Medical Staff did not establish criteria delineating the qualifications that an Emergency Department Physician must possess in order to supervise the provision of Emergency Care Services.

This failure may lead to a non-qualified Physician supervising the provision of Emergency Care Services.


The facility's current Medical Staff Bylaws did not contain established criteria including the necessary education, experience or specialized training, delineating the qualifications that a Medical Staff Member must possess in order to provide supervision of Emergency Care Services.

The facility's Emergency Department: Plan for Providing Care / Services dated July 2015, states "The Emergency Department Physician staffing is the responsibility of the Chairmen" but lacked any information regarding designation of a Charge Physician or the qualifications required for this designation.

During an interview on 07/21/16 at 11:30AM, Staff L, ED Medical Director, stated that "The Team Two Doctor is designated as the Charge Physician for the Unit". When asked if there were specific criteria delineating the qualifications the Physician must possess in order to supervise Emergency Care Services, he responded that to his knowledge "There is no written criteria for designating the role of the Charge Emergency Physician". This was confirmed during an interview in the afternoon by Staff D, Senior Vice President of Administration.