| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 01C0001010 | (X3) Date Survey Completed 09/19/2019 |
| Name of Provider or Supplier The Southern Alabama Surgery Center, Llc | Street Address, City, State 2800 Ross Clark Circle, Suite 3, Dothan, AL | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| Q0181 | ADMINISTRATION OF DRUGS CFR(s): 416.48(a) Drugs must be prepared and administered according to established policies and acceptable standards of practice. This STANDARD is not met as evidenced by: Based on review of facility policies and procedures, observations and staff interviews, it was determined the facility failed to ensure staff labeled all medications after opening as directed per facility policy and all medications and supplies were safe for patient use and not expired. This had the potential to negatively affect all patient served by the facility. Findings include: Policy: Expired Medications/Controlled Drug Disposal Policy Number: None Date: None Policy: All medications will be monitored for expiration. Expired medications will be immediately removed and disposed of according to policy. Purpose: To maintain an inventory of active pharmaceuticals Procedure: ...All areas of the Center will monitor drug inventory on a monthly basis for expiration dates. Policy: Expired Solutions and Supplies Policy Number: None Date: None Policy: Surgery Center South will have a policy for the monitoring and disposal of expired products, including all supplies, solutions, and any other items with expiration dates. Purpose: To ensure all expired items are removed and disposed of properly Procedure: All areas of the Center (including crash carts) will be checked monthly for expired products... Policy: Emergency Code Cart Policy Number: None Date: None Policy: Emergency equipment is readily accessible at all times. Purpose: To ensure the Center's ability to respond immediately to life threatening situations. Procedure: A binder will be maintained on the Code Cart and will include: ...Monthly code cart inventory to include: ...Emergency Drug (to include expiration dates) and supply list... ...Emergency drugs will be restocked as needed and checked for expiration dates on a monthly basis... Policy: Multi-Dose Vials Policy Number: None Date: None Policy: Multi-use vials will be discarded when empty, 28 days after opening, at the manufacture's expiration date, if there is obvious or suspected contamination, or at the recommendation of the manufacture. Procedure: ...Medication with a limited shelf life after opening will be dated and initialed. Policy: Malignant Hyperthermia Cart Policy Number: None Date: None Malignant Hyperthermia cart shall be restocked and checked at least monthly and after every use. Monthly checks shall include checking of expiration dates. If there is an item nearing expiration, the item is replaced... 1. A tour of the facility was conducted on 9/17/19 at 9:10 AM with Employee Identifier (EI) # 1, Director of Nursing (DON). During the tour of the facility the recovery area of the eye surgery side was observed which included 10 bays. Observations in the eye recovery area revealed in bay # 10 the following: 1 - opened bottle of Peroxide without an open date and the lid was only partially on the bottle. 1- open 500 ml (milliter) bottle of Sterile Water without an open date on the bottle. 39- Percocet were in the narcotic lock up box and had the expiration date of 7/19. An interview was conducted on 9/17/19 at 9:35 AM with EI # 1 who confirmed the above mentioned findings. 2. An observation was conducted on 9/17/19 at 9:45 AM to observe the pre (before)/post (after) op (operation) sections of the GI (Gastrointestinal) area. During the tour, the medication cupboard was checked and the following medication was found to be expired: Midazolam HCL (Hydrochloride) 2 mg (milligram) per 1 ml in a 110 ml bottle with an expiration date of August 19, 2019. An interview was conducted on 9/17/19 at 10:00 AM with EI # 1 who confirmed the above mentioned findings. 3. An observation was conducted on 9/17/19 at 10:05 AM of all vacant OR (operating room) suites. Observation of OR suite # 11 revealed near the anesthesia cart a 250 ml bottle of Servoflurane inhalation anesthetic. The bottle contained approximately 75 ml of solution and no open date label was on the bottle. An interview was conducted on 9/17/19 at 10:30 AM with EI # 1 who confirmed the above mentioned findings. 4. An observation was conducted on 9/17/19 at 11:00 AM in the hallway of the OR suites # 1- 6 to observe the crash cart. Observation of the crash cart revealed the following medication and supplies were expired: 1- 10 ml bottle of Epinephrine expired 8/19 4- 0.9% Normal Saline (NS) flushes expired 7/31/19 1- 0.9% NS flush expired 8/31/19 1- Adult CO2 (Carbon dioxide detector) expired 8/6/19 2- 500 ml bags of Lipids expired 8/19 An interview was conducted on 9/17/19 at 11:20 AM with EI # 1 who confirmed the above mentioned findings. 5. An observation was conducted on 9/17/19 at 11:25 AM to observe the Hyperthermia cart. Observation of the Hyperthermia cart revealed the following medications and supplies were expired: 1- esophageal stethoscope with temperature probe expired 8/19 5- 60 ml syringes expired 5/14 5- mini spike dispensing pins expired 7/18 2- red top blood vials expired 5/18 1 blue top blood vial expired 6/30/18 1- green top blood vial expired 11/30/18 1- purple top blood vial expired 6/30/18 1- orange top blood vial expired 5/31/18 4- tegaderm expired 2018 4- Jelco 18 gage needles expired 6/19. An interview was conducted on 9/17/19 at 11:50 AM with EI # 1 who confirmed the above mentioned findings. 6. An observation was conducted on 9/17/19 at 11:50 AM to observe the difficult airway cart. Observation of the difficult airway cart revealed the following supplies were expired: 1- oral airway 6.5 mm (millimeters) expired 7/19 1- laryngeal mask airway expired 8/19 1- laryngeal mask airway expired 4/19 1- laryngeal mask airway expired 5/19 An interview was conducted on 9/17/19 at 12:10 PM with EI # 1 who confirmed the above mentioned findings. |