HospitalInspections.org

Based on observation and interview, the provider failed to have an effective system in place for the retrieval of employee records for the following:
*Four of eight human resource employee (J, K, L, and M) records were not accessible for review during the survey process.
*Eight of eight employee (F, G, H, I, J, K, L, and M) online training records were not accessible for review during the survey process.
-Employees G and I were licensed individuals. Their licenses could not be reviewed at the time of the survey.
Findings include:

1. On 7/10/17 during the 1:15 p.m. entrance conference it was noted by the ancillary/student health manager E :
*For approximately a year and a half the employee records have been completed and stored electronically.
*They currently had their existing paper employee files in boxes ready to ship to Sioux Falls to be scanned into the electronic records.
-Since those records were in boxes they might need some extra time to retrieve those paper employee records.

On 7/11/17 at approximately 2:00 p.m. a request for the human resource files, health files, and training records was given to the provider for eight employees (F, G, H, I, J, K, L, and M) selected at random by the survey team.

On 7/11/17 at approximately 4:30 p.m. the provider supplied the survey team with paper records for four employees (F, G, H, and I) and the health files for all eight employees (F, G, H, I, J, K, L, and M). Ancillary/student health manager E stated the other four records (J, K, L, and M) and all eight of the training records were electronic records. A request had been made to retrieve those electronic records, but they were not accessible yet.

On 7/12/17 at approximately 10:00 a.m. the ancillary/student health manager E stated they were still trying to get access to those above electronic records.

On 7/12/17 at approximately 11:30 a.m. the ancillary/student health manager E stated they were still trying to get access to those electronic records.

On 7/12/17 at approximately 2:00 p.m. the ancillary/student health manager E stated they were still trying to get access to those electronic records. They had made several requests, and it was unclear when access to those records would be available. A policy for the storage and retrieval of employee records was requested at that time. She was not aware of any policies in regards to storage and retrieval of employee records. She would look and e-mail that policy to the survey team if she found one. As of 7/17/17 no policy had been received from the provider.

Based on observation, interview, and policy review. the provider failed to ensure only authorized personnel had access to medication including:
*One of one locked medication room (medical unit) with key-card access provided to unlicensed staff including health unit coordinators and certified nursing assistants.
*One of one nursery refrigerator containing unsecured medications.
*One of one unlocked medication room (emergency department).
Findings include:

1. Observation on 7/11/17 at 10:35 a.m. of the medical unit medication room revealed the door was locked. Upon being notified this surveyor was waiting for someone to let her into the medication room, unit secretary A opened the door with a key-card swipe system. Items inside the medication room had included:
*A locked computerized medication system.
*An unsecured refrigerator containing non-narcotic medications requiring refrigeration.
*Two unsecured plastic multiple-drawer containers. Those containers:
-Were placed on the countertop.
-Were labeled with current patient names.
-Contained various non-narcotic medications.
*An unsecured black medication waste container:
-Had an approximately five-inch opening.
-Contents of the waste container had included vials of partially used non-narcotic medications awaiting removal to a medication waste disposal facility.

Interview at that time with the unit secretary regarding her responsibilities in the medication room revealed her job required her to:
*Place new patient labels on the medication drawers.
*Enter the room to check the refrigerator if the refrigerator alarm sounded.

Interview at that time with registered nurse (RN)/team leader N and pharmacy manager O regarding unit secretary access to the above revealed:
*RN N stated she was not sure why the unit secretary would have key-card access to the medication room.
*Pharmacy manager O was not aware the unit secretaries had key-card access to the medication room.
*Both RN N and pharmacy manger O confirmed unit secretaries were not authorized to have access to medications.

Interview on 7/11/17 at 1:30 p.m. with pharmacy manager O regarding unauthorized access to the inpatient medications in unsecured drawers on the counter and to the black waste containers revealed:
*The pharmacy used the small medication drawers on the counter to provide daily medications for each inpatient rather than utilizing the computerized secured medication system.
*Patients who entered the hospital might have required medications not found in the computerized system.
*Placing those medications in the system was a complicated process.
*The waste container did not contain narcotic medications.
*She confirmed the unit secretaries were not authorized to have access to any medications.
*She was not aware until that day that the unit secretaries and certified nursing assistants (CNA) had access to the medication room.
*She had taken that concern to the administration and chief nursing officer over a year ago and was told those unauthorized employees had been removed from the security key code clearance.



29354


2. Observation on 7/11/17 at 10:10 a.m. with RN C in the nursery revealed:
*A small refrigerator.
*Inside of the refrigerator were several vials of Methergine and Hepatitis B vaccine.
*There had not been a lock on the outside of the refrigerator.

Surveyor: 32332
Interview on 7/11/17 at 1:30 p.m. with the pharmacy manager O regarding the unlocked medication refrigerator in the nursery revealed:*The medication refrigerator was placed in the nursery for easy access to needed medications due to hospital construction and remodeling.
*She confirmed:
-The medication was not secured.
-CNAs had access to the nursery.
-The construction had been completed, and the medications should have had restricted access.

Surveyor: 29354
3a. Observation on 7/10/17 at 3:40 p.m. in the Emergency Department revealed:
*An opened door leading into a room with the Pyxis medication system.
*In an unsecured drawer was:
-An opened vial of Lidocaine HCL 1% and Epinephrine 1:100,000 injection with an expiration date of 2/1/18.
--There was no date on the bottle when it had been opened.
-One sealed bottle of Lidocaine 1%, 200 milligram/20 milliliter vial with an expiration date of 9/1/18.

Interview on 7/11/17 at 3:50 p.m. with the emergency department director regarding the unlocked door leading into the Pyxis system revealed:
*The door did not lock.
*It should have been closed at all times.
*Any staff member could have had access to the room.
*The two Lidocaine vials should not have been left in an unlocked drawer.

Surveyor 32332
b. Observation on 7/12/17 at 10:15 a.m. of the emergency department medication room revealed:
*The door was partially opened and unlocked.
*Unit secretary B entered the room unattended.
*The black medication waste container had been placed on the counter. The lid was not attached to the container.
*Several partially used bottles of non-narcotic medications in liquid and tablet form had been discarded in the waste container.
*An unopened bottle of Lidocaine was found in a sharps container located next to the black waste medication container.

4. Interview on 7/12/17 at 9:30 a.m. with the chief nursing officer (CNO) and the hospital administrator regarding the unauthorized access to the medication areas revealed:
*The CNO did not recall discussing the security clearance of the unit secretaries and CNAs with the pharmacy manager.
*The CNO and administrator confirmed all unauthorized personnel including the unit secretaries and CNAs should not have had access to any medications.

Interview on 7/12/17 at 11:30 a.m. with pharmacy manager O and quality coordinator P revealed pharmacy manager O confirmed:
*She had not audited the key code security of the medication rooms for access by unauthorized personnel for over one year.
*She had been told over one year ago the security had been restricted to authorized personnel only.
*The medication waste containers had not been restricted to employees with authorized access to medications.
*All medications should have been secured from unauthorized personnel.

Review of the provider's May 2017 Medication Storage policy revealed:*Medications were to have been stored in areas that were inaccessible to patients and visitors.
*All medication rooms, carts, and cabinets were to have been locked up when unattended.
*"Medications may not be stored on counter tops or on medication cart work surface."

Review of the provider's March 2017 Waste Disposal policy revealed:
*The purpose was to protect the health and well-being of patients, staff, visitors, and the surrounding environment.
*All regulated and unregulated medical or chemical waste was to have been disposed of according to departmental procedure according to federal, state, and local regulatory agencies.*There was no further information regarding how that black medication waste was to have been securely stored on the medical units.

Review of the provider's May 2017 Pharmacy Supervision policy revealed the director of the pharmacy was responsible for organizing and directing department operation, establishing policies and procedures, and instructing and supervising personnel while adhering to all state and federal regulations.