HospitalInspections.org

Based on review of policy, review of Pyxis Medstation Controlled Drug Activities Verification Logs, review of All Station Events reports and interview, it was determined the facility failed to ensure audits were done on controlled substances at the end of each nurses' shift in that 155 of 243 nurses did not sign the Pyxis Medstation Controlled Drug Activities Verification Log at the end of their shift indicating they reviewed their activities and there were no controlled substance discrepancies. By not verifying there were no controlled substance discrepancies at the end of their shifts, the likelihood existed for discrepancies to be in the inventory and for the discrepancies to go unresolved. Findings follow:

A. Review of policy titled "Pyxis" stated "Every nurse will review their own Pyxis Controlled Drug Activity Report at the end of shift, review for accuracy, sign the Verification Log, date and circle shift worked."
B. Review of All Station Events report outlining controlled substance administration and Pyxis Medstation Controlled Drug Activities Verification Logs from 09/08/13 to 09/17/13 revealed 155 of 243 nurses did not verify a controlled substance audit was done at the end of their shift.
C. The findings were verified, through interview, by the Director of Nursing on 09/25/13 at 1:30 PM.

Based on review of Monthly Medication Storage Area Inspection Logs, review of policy and interview, it was determined the facility failed to inspect medication areas on a monthly basis for 7 (09/12 through 03/13) of 12 (09/12 through 08/13) months on 2nd floor and 5 (09/12 through 12/12 and 03/13) of 12 (09/12 through 08/13) months on 3rd floor. By not inspecting the medication storage areas monthly, the facility could not assure that all floor stocks were controlled. The failed practice had the likelihood to affect all patients who received medication from these areas. Findings follow:

A. Review of Monthly Medication Inspection Logs from 09/2012 through 08/2013 revealed monthly inspections were not performed for 7 (09/2012 through 03/2013) months on 2nd floor and 5 (09/2012 through 12/2012 and 03/2013) months on 3rd floor.
B. Review of Policy titled "Inspection of Medication Storage Areas" revealed "Inspections should be conducted monthly."
C. Findings were verified, through interview, with the Director of Pharmacy on 09/25/13 at 1010.

Based on observation and interview, it was determined the facility failed to maintain kitchen supplies (four baking pans, one cheese grater and four pot holders) in clean rust-free condition located in the therapy gym kitchen. The failed practice created the potential for food items to become contaminated with rust and other food particles, and could affect any patient consuming foods that have contacted these items. Findings follow.

A. During a tour of the therapy gym kitchen on 09/24/13 at 0950, one cheese grater and four baking pans were observed to be covered in rust and four of four hot pads were stained and contained crusted food residue.
B. During the tour, the Occupational Therapy Clinical Coordinator was asked if the patients ever consumed the food cooked in that kitchen. The Occupational Therapy Clinical Coordinator stated, "Yes, if they want to."