Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 013422 (X3) Date Survey Completed 01/03/2024
Name of Provider or Supplier Ochsner Health Center-Butler Street Address, City, State 1404 E Pushmataha Street, Butler, 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)
J0125 PROVISION OF SERVICES

491.9(b) Patient care policies. (3) The policies include: (iii) Rules for the storage, handling, and administration of drugs and biologicals.


This STANDARD is not met as evidenced by:
Based on observations, clinic policy and procedure, and interviews with staff, it was determined the clinic failed to ensure expired medical supplies and laboratory testing supplies were not available for patient use and failed to ensure the staff disinfected the medication vial septum prior to piercing with a needle when preparing injectable medications. This had the potential to affect all patients treated at this clinic. Findings include: Clinic Policy/Procedure: Medication Storage and Handling Policy Number: not documented Revised Date: 4/28/23 ...Single-dose vials of medications should be prepared in a RHC (Rural Health Clinic) in the following way: 1. Parental medications should be accessed in an aseptic manner...and the rubber septum should be disinfected with alcohol prior to piercing... 1. A tour of the laboratory testing room was conducted on 1/2/24 at 10:30 AM with Employee Identifier (EI) # 5, Radiology/Lab Technician. Located in the urine sample kit drawer were four Cobas PCR (brand name) Urine Sample Kits with an expiration date of 10/31/23 on each. 2. A tour of the patient treatment halls was conducted on 1/2/24 at 11:00 AM. In Exam Room # 3 the following out of date supplies were observed and available for patient use: Povidine Iodine four fluid ounce bottle with an expiration date of 7/21. Two Hibiclens four fluid ounce bottles with an expiration date 5/23 on each. Five Culture swab kits with an expiration date of 1/31/23 on each. In the medication storage area drawer, the surveyor observed the following: 13 Hemocult test strips in packets of three containting 39 test strips. Each test strip had an expiration date of 7/22. Hemocult developer 15 millimeters bottle with an expiration date of 9/23. In an interview conducted on 1/3/24 at 2:00 PM, EI # 1, Manager of Clinical Operations, confirmed the clinic failed to ensure out of date supplies were not available for patient use. 3. An observation of medication administration was conducted on 1/3/24 at 8:58 AM. EI # 7, Licensed Practical Nurse (LPN), removed the cap from a single dose vial of Toradol 60 mg (milligrams) then pierced the septum with the syringe needle and withdrew the medication. EI # 7 failed to disinfect the septum with alcohol prior to piercing. In an interview conducted on 1/3/24 at 2:00 PM, EI # 1 confirmed the staff failed to follow the clinic policy and disinfect the septum with alcohol.