Initial Comments:
This report is the result of an unannounced survey conducted on September 21, 2011, at the Allentown Medical Services. It was determined that the facility was in compliance with the requirements of the Pennsylvania Department of Health Regulations 28 Pa Code, Chapter 29, Subchapter D, Ambulatory Gynecological Surgery in Hospitals and Clinics.
Safe and Sanitary recommendations were provided to the facility in Tag 9999 - Recommendations. The facility is encouraged to provide a plan of correction.
Plan of Correction:
No POC Required STANDARD
Recommendation
Name - Component - 00
Observations:
Based on a tour of the facility on September 21, 2011, and interview with staff, it was determined that the Allentown Medical Services should address the following findings in order to ensure a safe and sanitary environment for its patients.
Findings include:
A tour of the facility was initiated at 10:30 AM on September 21, 2011.
Procedure Room 2: The emergency drug kit contained one vial of Procainamide 1 gram/2 ml., which expired on September 1, 2011.
Scrub Room: This room contained the biohazard trash, biohazard freezer, a sink and cabinets. On the top shelf of the cabinet above the sink, there were two syringes. Both syringes were filled with 10 cc. of a clear fluid. Each syringe contained a green sticker with the letter "L" written on the sticker. The syringes contained no other documentation or labeling. EMP1 confirmed there was no other documentation or labeling on the syringes and noted that these syringes were "locals" drawn up for patient use on September 19, 2011.
Recovery Area: The Recovery Area was an open room containing three black vinyl recliners for patients. There were no curtains between the chairs to provide patient privacy during recovery. Two of the three black vinyl recliners were held together with black duct tape. This finding was noted during the survey on May 26, 2011. The facility submitted a plan of correction which stated "Older recovery room chairs will be repaired or replaced." The date of completion for the plan of correction was August 5, 2011. Review of the facility's August 31, 2011, PA Patient Safety Committee Meeting minutes noted "5. Older recovery room chairs are being replaced."
Hallway: In the hallway space located outside the procedure rooms, there was a small refrigerator. The refrigerator held a container with five syringes, each containing 1 ml. of clear fluid. The syringes were labeled Methergine 0.2 mg., lot #50014, expiration 3/14. There was no documentation on the syringes to identify who drew up the Methergine or the date the Methergine was drawn up. EMP1 confirmed employees drawing up solutions into syringes for patient use were to initial the syringes and date the syringe when the medication was drawn up.
Adjacent to the sink in the hallway, there was a physician prescription pad containing nine blank prescription sheets. This prescription pad was lying in full view on the counter top. EMP1 confirmed the prescription pad was not in a secure location and removed the pad at the time of the tour.
Plan of Correction:POC is optional and not required.
The expired Procainamide vial has already been discarded.
Local anesthetics are drawn up daily and color-coded with a green sticker and labeled with the initial "L" which stands for locals. Our staff members have been instructed to initial all local anesthetics in the future.
All of the recovery room recliners are sturdy & safe to sit in. Two of the older recliners simply had small tears in the vinyl fabric which were closed with matching duct tape and covered with clean underpads and/or drapes. The recovery room chairs posed no threat to patient safety or comfort. Howerver, for aesthetic reasons, the chairs will be replaced in order to improve the cosmetic appearance of the office.
The manager will remind our staff that labels for syringes of methergine should include not only the medication name, strength, lot number & expiration date, all of which were noted by the Department to be on the methergine syringes at the time of their inspection, but in addition, the syringe should also have the initials of the staff member making the notation.
The prescription pad noted to be on a desktop was secured on the day that the Department was in our office.
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