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Based on review facility policies and procedures, medical records, and staff interview, it was determined that the facility failed to follow its policy regarding time limits for physician reorders of protective restraints for six (6) of thirty (30) sampled patient records (#s 5, 10, 11, 23, 27 and 28).

Findings were:

Review of facility policy, entitled Protective Restraints, ID #NSG.07.05-3D, last reviewed 06/21/2011, revealed that orders for restraints were to be time limited, with the start time noted, and that the order for restraints was not to exceed twenty-four (24) hours.

Six (6) of thirty (30) medical records reviewed (#s 5, 10, 11, 23, 27,and 28) lacked documentation of either the date or the date and time that the physician ordered restraints; therefore, preventing determination of the twenty-four (24) hour time limit.

During an interview on 02/17/2011 at 1:45 p.m. in the facility's Bridge Conference Room, the interim unit manager of the Spinal Cord Injury Unit 3 (employee # 30) confirmed that physicians failed to consistently date and time their orders for protective restraints.

Based on review of facility policies and procedures, observation, and staff interview, it was determined that the facility failed to ensure that outdated medications were not available for patient use.

Findings were:

Review of facility policy, entitled Outdated Drug Procedure, last revised 10-04, last reviewed 4-09, revealed that the Pharmacy Manager or his qualified designee would inspect floor stock and crash carts at least once a month and that documentation of findings would be kept according to regulatory requirements.

During a tour of the Pain Center on 2/15/2011 at 2:20 p.m. with the Nurse Manager of the Outpatient Department (employee #5), the following expired items were noted in the crash cart in the instrument preparation room:
1. Two (2) of two (2) Propanolol (used to treat high blood pressure and other heart conditions)1 milligram (mg)/milliliter (ml) vials, expired 1/31/2011;
2. Two (2) of two (2) Procainaminde (used to treat irregular heart rhythms) 1 gram/10 ml vials, expired 2/1/2011;
3. Two (2) of two (2) Sodium Chloride (salt solution) 30 ml vials, expired 2/1/2011; and
4. One (1) of two (2) Dobutamine (used to treat heart failure and shock) in 250 ml bag of D5W (5% dextrose in water), expired 1/31/2011.

During an interview with the Outpatient Department Nurse Manager at the time of discovery, he/she stated that it was the pharmacy department's responsibility to check and replace expired medications.

Based on observations during facility tour and staff interview, it was determined that the facility failed to safely store supplies and gas cylinders.

Findings were:

During a tour of the Dietary Department on 2/15/2010 at 2:15 p.m. with the dietary manager (employee #31), observation revealed that supplies in the storage areas, which included the dry goods storage areas, walk in freezers and coolers, and the tube feeding supply room, were stacked less than eighteen (18) inches from sprinkler heads. While on the tour, the dietary manger confirmed that the boxes were stacked too high, and staff had been instructed not to stack supplies near the sprinkler heads.

During the tour, in an area just before entrance into the kitchen, observation revealed three (3) unsecured compressed CO2 (carbon dioxide) canisters sitting on the floor. The dietary manager stated that the canisters were empty and were awaiting pick-up by the distributor.

Review of facility policy, entitled Medical Gas Cylinders, approval date 06/19/2009, revealed that large cylinders were to be maintained upright by a retaining chain/fastener.