Initial Comments:
This report is the result of an unannounced special monitoring survey conducted on September 20, 2011, at the American Women's 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 20, 2011, documentation review and staff interview, it was determined that the American Women's Services failed to maintain a safe and sanitary environment.
Findings include:
A tour of the facility was conducted on September 20, 2011, from approximately 9:30 AM to 11:30 AM. The following were observed:
1. Procedure Room 2: One expired container of potassium nitrate applicators.
2. Lab Room: Two unlabeled syringes with clear liquid contents found in the refrigerator. By interview it was determined that the contents of the syringes or the date they were drawn up could not be confirmed.
There was no manufacturer required control solution for the Hemoglobin and Hematocrit machine. By interview, it was learned that available solution expired August 31, 2011, and since that time a facility staff member who identified his/her self as "anemic" was using their own blood as a daily control.
3. Office/Medication Storage Cabinet Room: Previously identified environmental issues, including missing wall covering and ceiling tiles were not fixed at this time.
4. Recovery Area: Seats were being cleaned with an inappropriate cleanser.
5. Unused Storage Room: Missing ceiling tile and outdated heparinized capillary tubes.
6. Storage Room: Outdated disposable curettes and patient care items stored on the floor.
7. Emergency Medication Kit: Expired Atropine, Procainamide, Valium and a 22 gauge IV angiocatheter.
8. Controlled Medications: There was incomplete documentation related to tracking of controlled medications. The locked cabinet in the Office/Medication Storage Cabinet Room contained a bag with five pre-drawn syringes labeled "Twi" [Twilight - 2 mg Versed and 100 mcg Fentanyl]. A label on the front of the bag indicated that nine twilight syringes were drawn up on September 19, 2011.
Upon entrance to this room, a clipboard contained a tracking sheet which, by interview, was supposed to be completed by staff every time a Twilight medication syringe was requested from the RN. The last entry on the form was dated September 14, 2011. There were no entries to account for the four missing syringes.
A locked cabinet in the Storage Room contained 50 unopened vials of Fentanyl and 40 unopened vials of Midazolam.
Review of the controlled medication log revealed the most recent entries for Fentanyl and Midazolam were dated July 13, 2011. By interview, it was confirmed that documentation tracking of controlled medications was incomplete.
9. Personnel files: The RN in the recovery area still does not have current CPR certification.
Plan of Correction:POC is optional and not required.
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