HospitalInspections.org

Based on interviews and observation, the governing body failed to be responsible for services furnished in the hospital.

Findings were:

Facility policy ADM.1.22 titled " Standard Medication Usage " states, in part, " II. Procedure: D.) 1.) Inpatient and Emergency Services staff will conduct and document a physical count of all scheduled medications at each shift change. "

In an interview with staff #1 on the afternoon of 12-14-11, she stated that a physical count of all scheduled medications was conducted on a weekly basis.

Facility/pharmacy policy titled " Multiple Dose Vials " states, in part, " Multiple dose vials shall be dated and signed upon first entry and shall be used for 28 days only or until the vial has been compromised or the integrity of the stopper is questionable. "

During a tour of the patient care unit on 12-14-11, the following items were found in the medication room refrigerator:

· 1 of 1 multi-dose vial of Humalog insulin had been entered but was not dated or signed with the date of entry.
· 1 of 1 multi-dose vial of Novolin R insulin had been entered but was not dated or signed with the date of entry.
· 1 of 1 multi-dose vial of Novolog 70/30 insulin had been entered on 9-1-11 but was still available for patient use.
· 1 of 1 multi-dose vial of Novolin 70/30 insulin had been entered on 9-6-11 but was still available for patient use.
· 1 of 1 multi-dose vial of Lantus insulin had been entered but was not dated or signed with the date of entry.
· 1 of 1 multi-dose vial of Novolin N insulin had been entered but was not dated or signed with the date of entry.

The above was confirmed in an interview with the Chief Executive Officer and other administrative staff on the evening of 12-14-11 in the facility conference room.

Based on observation and a tour of the facility, outdated or otherwise unusable drugs were still available for patient use.

Findings were:

Facility/pharmacy policy titled " Multiple Dose Vials " states, in part, " Multiple dose vials shall be dated and signed upon first entry and shall be used for 28 days only or until the vial has been compromised or the integrity of the stopper is questionable. "

During a tour of the patient care unit on 12-14-11, the following items were found in the medication room refrigerator:

· 1 of 1 multi-dose vial of Humalog insulin had been entered but was not dated or signed with the date of entry.
· 1 of 1 multi-dose vial of Novolin R insulin had been entered but was not dated or signed with the date of entry.
· 1 of 1 multi-dose vial of Novolog 70/30 insulin had been entered on 9-1-11 but was still available for patient use.
· 1 of 1 multi-dose vial of Novolin 70/30 insulin had been entered on 9-6-11 but was still available for patient use.
· 1 of 1 multi-dose vial of Lantus insulin had been entered but was not dated or signed with the date of entry.
· 1 of 1 multi-dose vial of Novolin N insulin had been entered but was not dated or signed with the date of entry.

The above was confirmed in an interview with the Chief Executive Officer and other administrative staff on the evening of 12-14-11 in the facility conference room.

Based on observation, interview, and a tour of the facility it was determined that the facility did not ensure a the condition of physical plant was maintained in a manner to assure the safety and well being patients.

Findings were:
A tour of the operating area of the hospital on 12-14-11 revealed several infection control issues. Observation of the Endoscopy room revealed 7 holes approximately ¼ inch in circumference in the flooring. Operating Room # 1 had significant chips and cracks in the cement base where the floor and wall meet on all four walls, ranging in size from 1/4 inch to 5 inches wide. The metal doorframe to the OR #1was also rusted in several areas on the interior of the room. There was an area of broken wall tiles against the door frame, approximately 4 inches long. Operating Room # 2 also had significant chips and cracks in the cement base where the floor and wall meet on all four walls, ranging in size from 1/4 inch to 5 inches wide. The cracks and holes in the flooring provided an opening for dirt particles, rodents and insects. These areas are unable to be properly cleaned or disinfected, increasing the risk of cross contamination.

The above was confirmed in an interview with the Chief Executive Officer and other administrative staff on the evening of 12-14-11 in the facility conference room.