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Based on observation, review of records, and interviews, the pharmacy had not provided adequate controls over all drugs in their drug storage areas, in that, two different types of insulin was available for use in an individual medication drawer, other than the type of insulin currently ordered for 1 of 1 patients (Patient # 17).

Findings include:

On a tour the morning of 10/18/10 with the acting Director of Nurses (Personnel # 8), the surveyor observed 3 types of insulin in Patient # 17's individual medication drawer for Room # 111, in the locked medication cart. This drawer contained the following insulins:
-2 Lantus insulin bottles, opened.
-2 Novolog insulin bottles, opened.
-1 Novolin R insulin bottle, opened, and labeled with a discharged patient's name and Room # 123.

Review of Patient # 17's medication administration record (MAR) showed that the only insulin this patient had currently ordered was the Novolin R per sliding scale protocol. However, this bottle was opened and had been labeled for another patient (Patient # 18).
The extra 2 bottles of Lantus and 2 bottles of Novolog insulins were not ordered for Patient # 17, but were available for patient use in his medication drawer.

-The "General Dispensing of Medications" policy # CM-MM-H-0031, dated 01/01/09, noted under Pharmacist's Responsibilities, # 13, that "discontinued drugs, drugs remaining after a patient is discharged, excessive drugs, and unusable drugs shall be returned to the pharmacy in a timely manner."

In an interview the morning of 10/18/10 with the pharmacist on the nursing unit (Personnel # 14), she was asked who was responsible for the ensuring that correct medications were in each patient's medication drawer, specifically multi-dose insulin bottles. She stated that the pharmacy process was to do a full medication cart exchange, re-stocking each patient's medication drawer with their current medications every Monday, Wednesday and Friday, except for insulins. When asked why there were 3 types of insulins in Patient # 17"s medication drawer, including one marked with a discharged patient's name and room number, and verifying that he had only 1 type of insulin ordered, she said she did not know. Personnel # 14 also confirmed that she did not know why the pharmacy had not been checking or changing out insulins routinely as needed, and in the same manner as all other drugs.

Based on observation, review of records, and interviews, the hospital had not ensured that outdated, unusable drugs were not available for patient use, in that, expired drugs and biologicals were observed in 2 of 3 patient care areas surveyed.

Findings include:

On tours the morning of 10/18/10, the surveyors observed expired drugs and biologicals available for patient use as noted in the following areas of the hospital:
High Observation Unit (HOU) Medication Room:
4 - Kaletra 200/50 milligrams (mg.), expired 01/21/01.
4 - Amiodarone injectable, (an emergency drug), expired 09/10.
1 - Kaopectate oral suspension, expired 10/03/10.
High Observation Unit Crash Cart:
1 - Nitroglycerin 250 milliliter (ml.) bottle, expired 10/01/10.
Emergency Treatment Room:
1- Tube of wound care cream, expired 09/01/09.

The hospital's Policies & Procedures regarding expired drugs and biologicals showed the following:
-The "General Dispensing of Medications" policy # CM-MM-H-0031, dated 01/01/09, noted under Pharmacist's Responsibilities, # 13, "that unusable drugs shall be returned to the pharmacy in a timely manner."
-The "Emergency Drugs" policy # MM.63, undated, noted under Controlling Emergency Drug Supplies - Inspection Procedure, (a) The pharmacy shall inspect emergency drugs at least once a month and after each use..." and (# 6) "the pharmacy shall replace missing, expired, and unusable drugs as soon as possible."
-The "Crash Cart Check" policy # CM-PC-H-0072, dated 01/01809, noted under 2.1, Pharmacy, that "drugs will be checked monthly for expiration dates..."

In interviews the morning of 10/18/10 with the HOU charge nurse (Personnel # 13), and the Quality Assurance Manager (Personnel # 2), they each verified the above drugs and biologicals were expired and available for patient use.

Based on observation, review of records, and interviews, the hospital failed to ensure that supplies were safely maintained, in that, expired supplies were available for patient use in 2 of 3 patient care areas surveyed.

Findings include:

On a tour of the inpatient care areas the morning of 10/18/10, the surveyors observed the following expired supplies available for patient use:

Medical/Surgical Unit, East Hall Crash Cart:
3 - Arterial blood sampling kits, expired 11/09.

High Observation Unit, Crash Cart:
1 - Arterial blood sampling kit, expired 07/10.
1 - Intravenous (IV) start kit, expired 08/10.
1 - Tracheal tube, size 7.5, expired 03/10.
1 - 18 gauge needle, expired 08/10.
3 - 18 gauge angiocath needles, expired 08/10.

High Observation Unit, Medication Room:
1 - 16 gauge angiocath, expired 08/09.
1 - glucose control solution, level 1, expired 11/09.
1 - glucose control solution, level 2, expired 11/09.

The hospital "Safety Management Standards of Performance" policy # MS-EC-H-0048, dated 01/01/09, noted that the facility will perform "safety monitoring activities...that "are critical for assuring the safety of out patients...," but did not specifically address removing expired equipment and supplies from patient care areas to ensure an acceptable level of safety.

In interviews the morning of 10/18/10, the HOU charge nurse, (Personnel # 13), and the Quality Assurance Manager (Personnel #2), verified these patient care supplies were expired. Both nurses agreed that these supplies had been available for patient use.

Based on observation, interview, and record review, the facility did not maintain an on call list of physicians, and there were no written policies and procedures in place to respond to situations in which a specialty physician was not available or when the on-call physician could not respond because of circumstances beyond the physician's control.

Findings included:

A tour of the emergency treatment room was conducted the morning of 10/18/10 with Personnel #2. It was observed that there was no schedule of on-call physicians available in the treatment room. Personnel #2 was asked to provide the on-call physician list.

The "Physician Coverage" list provided did not include physicians on the 7 AM to 7 PM shift. The list indicated "If anyone fails to show up or you have questions, please call..."

In an interview the afternoon of 10/18/10, Personnel #1 was asked if the facility has on-call physician coverage from 7 AM to 7 PM to respond to emergency situations. Personnel #1 stated that there was no schedule available and that the physician who was in the facility that day will be the one to respond to emergencies. Personnel #1 was asked if there was a policy & procedure to follow if a physician could not respond to an emergency. Personnel #1 replied "no."

Policy #CM-PC-H-0122 "Emergency Treatment Services" dated 01/01/09 required "The Hospital will maintain a physician On-Call schedule to respond to emergency treatment room needs." The policy did not include procedures if an on-call physician could not respond because of circumstances beyond the physician's control.

Based on observation, review of records, and interview the hospital had not evaluated contract dietary services in their hospital-wide QAPI program, in that, food temperatures had not been monitored to ensure patient safety in accordance with hospital infection control policy and procedures.

Findings include:

On a tour during the hospital lunch period on 10/19/10 with the Dietary Director (Personnel # 11), the surveyor observed the temperature testing of a test tray prepared by the contract food service provider as it reached the nursing unit. The "cold" food (pudding for dessert) was delivered to the patient floor at a temperature of 65 degrees.

The hospital's "Food and Nutritional Role in Infection Control" policy # QM-IC-H-0037, dated 01/01/09, noted these procedures were to be followed:
-"3.5- Utilizes quality control processes to ensure stability, proper labeling, storage of food and food supplies."
-"3.7- Department Director is responsible for monitoring departmental compliance with IC (Infection Control) policies and procedures, including education and practice issues."
-"5.2- Serve food as soon after preparation as possible. If foods are to be served cold, they must be kept at room temperature below 40 degrees...The danger zone from 40 degrees (cold food) - 140 degrees (hot food) Farenheit is the temperature zone in which harmful bacteria grow and produce toxins."

In an interview at noon on 10/19/10 with the Dietary Director (Personnel #11), when asked if the Dietary Department had been monitoring temperatures of foods delivered for hospital patients as part of their QAPI process, and as oversight of this contracted service, she said "no."