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Based on observations, interviews and review of hospital policies, it was determined the hospital failed to ensure that expired medications were not available for patient use in the Emergency Department, Nuclear Medicine, and Operating Room (OR).

This had the potential to affect all patients.

Findings include:

Policies and Procedures:
Division: Nursing Emergency Department
Subject: Crash Cart/Exchange

Policy: Each patient care area at Randolph Medical Center will have a crash cart stocked as outlined which has a security lock ... Pharmacy personnel will perform checks on all carts every three months for currency of all drugs and supplies.

Procedure: Each crash cart will be checked every shift by licensed personnel ...


A tour of the Emergency Department was conducted on 7/20/10 at 1:10 PM. During this tour the surveyor and Employee Identifier (E.I.) # 1, Staff RN, observed the following medications with expired (exp) dates:

Trauma Room (Rm) # 3:

Activase Tray:
Dopamine HCL 800 Milligrams (mg) 10 (milliliters) ml x 1 bottle exp 5/1/10

Adult Crash Cart:
Sterile Water 10ml x 3 exp 5/1/09
0.9 % Sodium Chloride Injections x 3 bottles exp 11/1/09
HurriCaine Topical Anesthetic Spray x 1 can exp 4/09


Emergency Room Hallway:
Endal HD syrup x 6 syringes exp 6/10
Ativan 1 milligram (mg) tablets x 10 exp 5/10
Tylenol # 3 tablets x 18 exp 6/10


A tour of the Nuclear Medicine Department was conducted on 7/22/10 at 8:05 AM. During this tour the surveyor and Employee Identifier (E.I.) # 3, Director of Radiology, observed the following medications with expired dates:

Crash Cart Box:
Sodium Bicarbonate 50 ml x 2 exp 1/10
50% Dextrose 50 ml injection x 1 exp 7/1/10
Solu-Cortef 100 mg injection x 1 exp 4/10
Solu-Medrol 125 mg injection x 1 exp 11/09
Aminophylline 500 mg / 20 ml x 2 exp 1/10
Epinephrine 1:1000 injection x 1 exp 7/1/10
Decadron 4 mg / ml injection x 1 exp 1/10
Diphenhydramine 50 mg / ml x 1 exp 3/10
Naloxone HCL 0.4 mg / ml x 4 exp 2/1/10
0.9% Sodium Chloride 10 ml x 3 exp 6/1/10




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A tour with EI # 4, the Director of Nursing, of the OR on 7/21/10 at 10:15 AM the following expired medications were found in an unlocked Anesthesia Supply Cart:
1 vial of Adenosine 6 mg (milligrams)/2 ml (milliliter) expired in May 2010
1 vial of Naloxone Hydrochloride 0.4 mg/ml expired on 1 October 2009
1 10 ml vial of Succinyl Choline 200 mg (20 mg/ml) expired on 1 July 2010
1 1 ml vial of Atropine 0.4 mg/ml expired in February 2010

An interview with EI #4 at 10:15 AM confirmed the aforementioned medications were expired.

Based on observations, interviews and review of hospital policies, it was determined the hospital failed to ensure that expired (exp) supplies were not available for patient use in the Emergency Department, Operating Room (OR) and Sterile Supply Storage Room.

This had the potential to affect all patients.

Findings include:

Policies and Procedures:
Division: Nursing Emergency Department
Subject: Crash Cart/Exchange

Policy: Each patient care area at Randolph Medical Center will have a crash cart stocked as outlined which has a security lock ... Pharmacy personnel will perform checks on all carts every three months for currency of all drugs and supplies.

Procedure: Each crash cart will be checked every shift by licensed personnel ...


A tour of the Emergency Department was conducted on 7/20/10 at 1:10 PM. During this tour the surveyor and Employee Identifier (E.I.) # 1, Staff RN, observed the following supplies with expired dates:

Clinic Room (Rm) # 4:
0.9% Sodium Chloride 250 milliliters (ml) times (x) 1 opened and not dated
Lemon Prep Skin Prep x 1 bottle expired (exp) 10/08

Trauma Rm # 3:

Pediatric Crash Cart:
Umbilical Vessel Catheter Insertion Tray x 1 exp 10/05
Intravenous (IV) Start Kit x 4 exp 6/10
Intravenous (IV) Start Kit x 2 exp 5/10
Intravenous (IV) Start Kit x 2 exp 12/02
Intravenous (IV) Start Kit x 2 exp 9/03
Povidone - Iodine Prep Swab sticks x 6 exp 1/04
Povidone - Iodine Prep Swab sticks x 2 exp 7/03
24 gauge (ga) Insyte IV catheter x 2 exp 6/10
24 ga Insyte IV catheter x 1 exp 5/10
18 ga Angiocath x 3 exp 7/06
18 ga Angiocath x 1 exp 4/08
18 ga Angiocath x 1 exp 1/06
20 ga Jelco IV catheter x 2 exp 2/04
20 ga Angiocath x 1 exp 1/06

Open Cabinet:
Petrolatum Gauze x 2 boxes exp 1/05
Petrolatum Gauze x 1 box exp 6/03
Povidone - Iodine Prep Swab sticks x 1 exp 1/04
Multi-Trauma Dressing Tray x 2 exp 9/06
Asorbable Hemostat x 1 box exp 4/00

Activase Tray:
Purple Top Blood Collection Tubes x 4 exp 4/04
Green Top Blood Collection Tubes x 4 exp 8/03

Suture Cabinet:
I-Stat Low Temp Cautery x 2 exp 2/14/10
2-0 Sofsilk x 1 box exp 3/10
4-0 Silk x 1 box exp 1/08
4-0 Surgipro Cutting Monofilament Polypropylene x 1 box exp 9/09

Respiratory Cart:
Tracheofix Uncuffed Tracheostomy Tube x 1 exp 8/06
Electrode Foam Pre-gelled Pad x 1 exp 6/06

Emergency Rm #1:
Iodoform Packing Strip x 1 bottle exp 9/09
Cotton Tip Applicators x 5 exp 10/09
Cotton Tip Applicators x 4 exp 6/09
Pope Ear Wick x 1 box exp 12/00
16 ga Insyte IV catheter x 2 exp 9/07



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On a tour of the Sterile Supply Storage room on 7/21/10 at 9:45 AM the following expired supplies were found:

1 Electrosurgical Pencil with the expiration date of April 2010
15 Electrosurgical Pencils with the expiration date of January 2008

An interview with E.I. # 4, the Director of Nursing (DON) on 7/21/10 at 9:45 AM confirmed the aforementioned supplies were expired.

On a tour of the OR on 7/21/10 at 10:00 AM the following expired supplies were found:

1 box of 50 Penrose Drains 12 inch/304.80 mm (millimeters) with the notation to use by October 2007
1 box of 50 Penrose Drains 12 inch/304.80 mm (millimeters) with the notation to use by November 2008

An interview with E.I. # 4 on 7/21/10 at 10:00 AM confirmed the aforementioned supplies were expired.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.

Based on observation the facility failed to assure that all medications requiring refrigeration were stored properly and in accordance with manufacturer ' s recommendations in the Emergency Department and Pharmacy.

This had the potential to affect all patients.

Findings Include:


A tour of the Emergency Department was conducted on 7/20/10 at 1:10 PM by the surveyor and Employee Identifier (E.I.) # 1, Staff RN. During the tour, a review of the temperature log for the medication refrigeration revealed the following:
a. no documentation that the temperature was monitored from February through May of 2010 and,
b. incomplete daily monitoring for January, June and July of 2010.

A tour of the Pharmacy was conducted on 7/21/10 at 9:00 AM by the surveyor and E.I. # 2, the Pharmacist. During the tour, the surveyor requested the temperature log for the medication refrigerator. E.I. # 2, the Pharmacist stated, "don't have one."

Further observation of the medication refrigerator revealed food being stored in both the freezer and refrigerator sections which contained medications.

Based on a tour of the Operating Room (OR) and an interview with Employee Identifier (EI) # 4, the Director of Nursing (DON), it was determined that the facility failed to assure that medications in the anesthesia supply cart were inaccessible to others. This had the potential for medication diversion.

Findings include:

On a tour of the OR on 7/21/10 at 10:15 AM, the blue anesthesia supply cart stored in the unlocked OR was observed to be unlocked. The top drawer of the cart contained medications that were accessible to anyone who came into the OR.

Review of the Register of Operations revealed that the last surgery performed in the OR was on 7/14/10.

An interview with EI #4 on 7/21/10 at 10:15 AM confirmed that the cart was not locked or stored in a locked room.

Based on medical record (MR) review and interview with Employee Identifier (EI) #4, the Director of Nursing (DON), the facility failed to ensure that care was administered as ordered by the physician for 1 of 3 patients with a wound and 1 of 1 patients receiving tube feedings (MR #11 and MR #16).

Findings include:
1. MR #11 was admitted to the facility on 6/19/10 with a primary diagnosis of Cellulitis related to an insect bite to the left upper inner thigh area.
The nursing note dated 6/19/10 at 5:05 PM revealed, "Possible insect bite to left inner thigh dry dressing placed over area because there is bloody drainage ozzing (oozing) from wound."
The nursing note dated 6/20/10 at 7:55 AM revealed, "....dressing changed ...."
The nursing note dated 6/21/10 at 7:54 PM revealed, "....dressing changed ....."
The nursing note dated 6/21/10 at 8:04 PM revealed, "Vaseline gauze applied to left inner thigh and covered with ABD (abdominal pad) ..."
The nursing note dated 6/22/10 at 9:44 AM revealed, "....applied pressure dressing, Area left open to air, Dressing changed ...."
The nursing note dated 6/22/10 at 11:15 AM revealed, "Left inner thigh wound cleaned with Betadine and dressing apply (applied)"
Review of the Physician's Progress Notes and the Physician's Orders revealed no documentation that staff was to be performing wound care or dressings to the insect bite area.
Interview with EI #4 on 7/22/10 at 1:10 PM confirmed that the nursing staff was performing wound care without having a physician's order to provide wound care. He/she confirmed that wound care should not have been performed without a physician's order.

2. MR #16 was admitted on 6/5/10 with the primary diagnosis of Acute Gastrointestinal Bleed.
The Physician's orders on admission on 6/5/10 at 2:00 AM were for the patient to be NPO (nothing by mouth).
The Physician's order dated 6/8/10 at 2:30 PM was, "Restart PEG (percutaneous endoscopic gastrostomy tube) tube feedings per Nursing Home Protocol (today)"
The Physician's order dated 6/8/10 at 3:30 PM was, "Hold tube feedings (due to possible EGD (Esophagogastroduodenoscopy) tomorrow ...."
The nursing note dated 6/9/10 at 10:12 AM revealed that the physician visited and "...states patient is going to go back to the nursing home, no tube feeding bag hanging, just gave Bolus of Jevity of 249 ML (milliliters) per PEG tube and pt tolerated it well and flushed PEG tube with 40 ML of water past bolus."
Interview with EI #4 on 7/22/10 at 1:05 PM confirmed that there was no physician ' s order for the patient to receive the bolus feeding.