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Based on staff interviews and administrative document review, the governing board (board of directors- BD) failed to ensure the consulting pharmacist (Rx1) fulfilled his responsibilities identified in the contract between Rx1 and the Hospital. This failure contributed to the hospital's inability to comply with pharmaceutical service obligations of the hospital to its patients.

Findings:

The executive director of patient care services (EDPCS) provided for review the contract between the hospital and Rx1. The first page, under "Description of Services", read: "... Consultant will provide the following services (collectively, the "services"): "Pharmacist-in-Charge" duties and general supervision of Hospital's drug room. Responsibilities shall also include any and all duties relative to Hospital's drug room licensing and all State Board of Pharmacy requirements for drug room services at Hospital. See Exhibit A for a complete list of Consultant responsibilities. In addition, Consultant shall meet with Hospital's Chief Nursing Officer (CNO) or its CEO as needed to discuss the services as described in Appendix A and in Section 1. Consultant agrees to devote sufficient hours, based on Hospital's need, to carry out Consultant's responsibilities. Services shall include, at a minimum, 5 routine visits to Hospital by Consultant each week ..."
Exhibit A reads as follows:
"1. The following will be reviewed and reconciled monthly, weekly, or daily as appropriate: ... "Code carts contents (emergency drugs) ..."
"2. The following services will be accomplished no less frequently than monthly: ... "Review and revision of Policy & Procedure Manual at least least annually ... Assurance of full compliance with all relevant regulations of CMS (Centers for Medicare and Medicaid), CDPH (California Department of Public Health) and the Board of Pharmacy ... Communication with Department of Nursing leadership to collaborate on practices that assure medication safety and reduced medication errors ... "
"3. A comprehensive report summarizing the findings of the above reviews shall be submitted monthly to Administration."
The contract was signed by Rx1 and the then CEO on 6/16/11 and remained in effect at the time of the survey.

During a meeting with the EDPCS, Chairman of the Board of Directors (CHBD) and the acting Chief Executive Officer (ACEO), on 5/3/13 starting at 11:30 AM, the EDPCS stated she was also the CNO. The CHBD stated that the duties of the EDPCS included being the CNO. The contract section identified above was read to the group. The CHBD asked the EDPCS if Rx1 had complied with the contract. The EDPCS stated Rx1 had not. The EDPCS further stated this was evident based upon the many pharmacy deficiencies found during the CMS survey which occurred in March 2013. The EDPCS stated she had no communication with Rx1 since 3/21/13 and Rx1 had not been available to assist in updating hospital's policies and procedures. The EDPCS also stated Rx1 had never submitted any reports to be reviewed.

During the same interview, the CHBD stated Rx1 was in breach of the contract and the contract was to be terminated. The EDPCS stated she was already searching for another Consultant Pharmacist. The CHBD also stated the Board of Directors was at fault for not making certain Rx1 complied with the terms of the contract.

Based on interview and document review, the hospital failed to ensure that two of 2 sampled medication errors were analyzed for their causes and corrective action taken in order to prevent their reoccurrences. This failure could result in preventable medication errors and possible harm and injury to patients.

Findings:

Medication errors provided by the executive director of patient care services (EDPCS) were reviewed with her on 5/1/13 starting at 9:30 AM. There were 2 reported errors in February 2013.

The 2 reported errors identified what the errors were but did not identify how they occurred or any action taken to prevent them from reoccurring. The EDPCS acknowledged that there was no evidence of the causes of the errors or any action taken to prevent their reoccurrences.

Based on staff interview and administrative document reviews, the hospital failed to ensure the consultant pharmacist supervised all the activities of the pharmacy services. This failure resulted in not providing the required oversight to ensure safe medication tracking, storage and administration and possibly increase the risk of patient medication error.

Findings:

During an interview with the executive director for patient care services (EDPCS) on 5/2/13 starting at 10:00 AM, she stated she hadn't seen or spoke with the consultant pharmacist (Rx1) since 3/18/13. The EDPCS further stated she received help in updating hospital policies and procedures from another pharmacist who could only help briefly. The question was asked if anyone else in the hospital had met with Rx1. The following email was received from the EDPCS on 5/3/13: "I just confirmed with Registered Nurse (RN)1 (sic) that she has only seen Rx1 (sic) one time for 5 minutes since our CMS survey in March. She said he came, did nothing and then left. RN1 also said he called her once to see what was going on with the state (survey) but that was the extent of their conversation. She called him once last week to ask if the testosterone had to be counted on the perpetual log."

The email from the EDPCS further stated "My assistant has not received any communications from him since (the) CMS (Centers for Medicare and Medicaid survey) ... in March. She did call him this week to ask if he knew of a Med Error Binder (a binder that holds documented incidents of possible medication errors) for 2012 and he did not."

"My last communications with our consulting pharmacist were as follows:
3/18/13 - I received a call from him stating that he was not available to meet with the pharmacist surveyor on 3/12 - 3/14 because of commitments at his other job. On 3/21/13 - He emailed me to remind me that the medications needed to be taken out of the ER (emergency room) and OR (operating room) and returned to pharmacy since the departments were closed. (which I had already done)."

During the interview with the EDPCS on 5/2/13 at 10 a.m., she indicated Rx1 had not helped in preparing any response to the CMS survey findings in March 2013 and was not even available during the survey to work with the pharmacist surveyor. As a result the EDPCS stated she was searching for another consultant pharmacist. The EDPCS confirmed the Rx1 provided no oversight or guidance to ensure medication safety and administration.

Based on observation, staff interview and review of manufacturer's directions, the hospital failed to ensure the proper storage for Xopenex (a medication used to open the airways of the lung). This failure resulted in not following the manufacturer's recommendation for medication storage and possibly affecting the efficacy (how well the medication works) on patients.

Findings:
A concurrent observation and interview was conducted with registered nurse (RN) 1 in the medication room starting at 8:45 AM on 5/1/13. An opened box of Xopenex (also known as Levalbuterol and is a medication that opens the airways of the lung and used in asthmatics) was found in the refrigerator. An opened foil pouch containing 4 unit-dose vials of the drug was found in the box. The date of 2/5/13 was written on the pouch which identified when the pouch was opened. The outside of the Xopenex pouch (the manufacturer's original pouch) contained the following directions: "Store at 20 - 25 degrees C (63 - 77 degrees F) ... Unit-dose vials should remain stored in the protective foil pouch at all times. Once the foil pouch is opened, the vials should be used within 2 weeks." According to the temperature log on the refrigerator, the refrigerator is kept at between 36 and 46 degrees F.
Thus, the box of Xopenex was stored incorrectly in the refrigerator and the foil pouch which was opened nearly 3 months earlier still contained unit-dose vials (medication container designed for one-time, one-patient use) of the drug contrary to the manufacturer's directions. RN1 confirmed the findings and stated that the consultant pharmacist told her to keep the Xopenex in the refrigerator.

Based on staff interview and dietary document review, the hospital failed to ensure that specific food and dietetic services organization requirements were met by failing to ensure there was a fulltime employee who served as director to food and dietetic services and was responsible for the day to day management. This failure could result in the hospital not providing safe food handling practices, supervision of work, orientation of food service staff, menu planning and quality operations for the food service and could negatively affect nutritional well being of all patients.

Findings:

On 4/30/13 starting at 8:30 a.m. the organization of the food and dietetic department was reviewed. Review of the organization of Dietary Services showed a part time consultant Registered Dietitian (RD) working to oversee the food service and clinical nutrition services to be provided to patients.

In an interview with the RD on 4/30/13 at 1:00 p.m., she stated the hospital was advertising for Dietary Service supervisor (DSS) but did not have any candidates at this time.

The hospital failed to employ a full time qualified Dietetic Service Supervisor responsible for the food service.

Interview with the interim CEO and CNO on 4/30/13 at 2:00 p.m., confirmed they were advertising for a fulltime qualified supervisor for the food service department but had not hired one at this time. They confirmed that the hospital recognized the need for a qualified Dietary Service Supervisor to ensure safe food preparation and supervision of the department. They confirmed the Registered Dietitian (RD) was consulting on a part time basis.