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Based on record review and interview, it was determined the facility failed to assure telephone and verbal orders were signed by the physician within 96 hours as required in the facility bylaws for 13 (#5, 9, 11, 12, 14, 15, 19, 21, 22, 23, 27, 28 and #30) of 30 (#1-#30) patients. The failed practice affected 13 patients and had the potential to affect all patients admitted to the facility. Without a signature on the telephone or verbal order, it could not be assured the physician had reviewed and approved the order. The findings were:

A. On 10/16-10/18/12 record review was conducted and revealed the following physician telephone or verbal orders that were not signed by the physician within 96 hours as required by facility bylaws:
1) Patient #5 had one order on 08/31/12 that was not signed.
2) Patient #9 had the following orders not signed 09/25/12 (1); 09/28/12 (2) and 09/29/12 (1).
3) Patient #11 had one order on 09/28/12 that was not signed.
4) Patient #12 had the following orders not signed 09/13/12 (3); 09/14/12 (1); 09/17/12 (4); 09/18/12 (2); 09/19/12 (2); 09/20/12 (1); 09/21/12 (2); 09/23/12 (3); 09/24/12 (2); 09/25/12 (1); 09/26/12 (1); 09/27/12 (2); 09/28/12 (3) and 10/01/12 (1).
5) Patient #14 had the following orders not signed 09/26/12 (6); 09/27/12 (5); 09/28/12 (3); 09/29/12 (2); 10/01/12 (1).
6) Patient #15 had the following orders not signed 09/25/12 (1); 09/26/12 (2) and 09/29/12 (4).
7) Patient #19 had the following orders not signed 09/21/12 (1); 09/22/12 (1); 09/25/12 (1); 09/27/12 (1) and 09/28/12 (1).
8) Patient #21 had the following orders not signed 09/17/12 (1); 09/19/12 (1); 09/23/12 (1); 09/24/12 (1) and 09/25/12 (1).
9) Patient #22 had the following orders not signed 09/25/12 (2) and 09/27/12 (1).
10) Patient #23 was admitted on 09/20/12. On 09/20/12 (3); 09/21/12 (2); 09/23/12 (2); 09/24/12 (1); 09/25/12 (2); 09/27/12 (3); 09/28/12 (3);10/10/12 (1) and 10/11/12 (1).
11) Patient #27 had the following orders not signed 09/04/12 (5); 09/05/12 (1); 09/06/12 (3); 09/08/12 (1); 09/11/12 (1); 09/13/12 (1); 09/15/12 (1) and 09/17/12 (3).
12) Patient #28 had the following orders not signed 09/25/12 (2); 09/27/12 (2);09/28/12 (2); and 09/29/12 (5).
13) Patient #30 had the following orders not signed 09/22/12 (1); 09/25/12 (3) and 09/27/12 (1).
B. The findings were confirmed at the time of clinical record review by RN (Registered Nurse) #2 for Patient #5, 11, 12, 14, 15, 21, 22, and #23 and RN #3 for Patient #9, 27, 28 and #30.

Based on observation, review of policy and interview, it was determined the facility failed to assure drug stock was properly controlled in that one of one Bronchoscopy Kit was maintained in the Respiratory Services office unknown to the Pharmacy. The kit contained medication in it and should have been under direct control of the Pharmacy. By pharmacy not being aware of the kit being stored in the hospital, pharmacy could not fulfill their obligation to conduct monthly checks on it to maintain the medications according to the hospital's policies and procedures and the manufacturer's recommendation. Findings follow:

A. Observation on 10/15/12 between 0935 and 1035 revealed a Bronchoscopy Kit that contained 4 Lidocaine 1% 20 milliliter (ml) bottles for injection and 2 Viscous Lidocaine 20 ml cups was stored in the Respiratory Services office. The Director of Pharmacy was not aware of the kit, therefore was not conducting the required monthly inspections on it.
B. Review of policy titled "Inspections of Medication Storage area on Patient Care Units" stated "All patient care units will be inspected, as well as any specialty areas where medication is dispensed, administered, or stored."
C. Findings were verified, through interview, at the time of observation with the Director of Pharmacy.

Based on observation, review of policy and interview, it was determined the facility failed to properly label one of one syringe for a patient in that a nurse withdrew the contents of a carpuject vial into another syringe containing normal saline, recapped the syringe and put the unlabeled syringe in her pocket. By not labeling the syringe, the facility could not assure the contents of the syringe, who the contents of the syringe were for, when the contents were drawn up or when they expired. The potential existed for a medication administration error along with the potential of adverse outcomes. Findings follow:

A. Observation on 10/15/12 at 0940 revealed RN (Registered Nurse) #1 withdrew contents of a 4 milligram Morphine carpuject vial, into a syringe that already had normal saline in it, re-capped the needle, and placed the syringe of diluted Morphine in her right pocket, unlabeled.
B. Review of policy titled "Medication Administration" stated "Medications will be labeled with the following: name of drug, time/date of preparation, initials of preparer, patient's name, and concentration of solution. Medications removed from the original container that are not used immediately, must also contain a 24 hour expiration date and time ..." This policy also stated "Medications removed from the original (container) that are NOT prepared at the patient's bedside must be labeled with the drug: name, strength, dose/amount, expiration date and time if not used within 24 hours."
C. Findings were verified through interview, with the Director of Pharmacy, RN #1 and the Director of Nursing on 10/015/12 at 1055.

Based fire drill documentation review and interview, it could not be determined a fire drill was performed on the second shift for 2011 and 2012. Failure to perform quarterly fire drills on each shift prevented the facility from ensuring staff are trained and prepared to respond to fire emergencies with required procedures in a prompt and orderly manner to protect patients from fire and smoke. The failed practice had the potential to affect all patients, staff and visitors and 25 of 25 patients on 10/15/12. See K50.