HospitalInspections.org

Based on document review and interview, the facility failed to ensure pharmacy policies were implemented for 6 of 6 staff members (RN #1, 2, 3, 4, 5 and 6).

Findings include:

1. Personnel files for RN #1-6 lacked evidence that the staff received pharmacy training upon hire for mixing sterile preparations per policy.

2. Pharmacy policy titled "Sterile Preparations: Immediate Use Compounded Sterile Preparations" last reviewed/revised 4/11/11 allows for preparation on patient care or procedural units and states on page 1 under procedure: "....The preparation is mixed by an individual authorized by the hospital and who has completed appropriate instruction and documented competence to mix Immediate Use sterile preparations......"

3. Facility policy titled "Scope of Pharmacy Services" last reviewed/revised 6/12 states on page 2: "Participation in in-service education programs for the professional and nonprofessional staffs of the hospital."

4. Staff member #5 (RN Nurse Manager for ICU) indicated the following in interview beginning at 12:00 p.m. on 10/6/14:
(A) Nurses can and do mix Amiodarone, Insulin, Levophed, and Cardizem.

5. RN #4 indicated the following in interview beginning at 12:45 p.m. on 10/6/14:
(A) He/she has had to mix Amiodarone, antibiotics and Cardizem.

6. Staff member #1 verified in interview at 5:00 p.m. on 10/7/14 that the personnel files lacked evidence of training per policy for RNs #1-6 as indicated above.