| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 013434 | (X3) Date Survey Completed 02/01/2018 |
| Name of Provider or Supplier River Region Family Medicine | Street Address, City, State 41 Cambridge Court, Wetumpka, 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) |
| J0023 | MAINTENANCE CFR(s): 491.6(b)(2) Drugs and biologicals are appropriately stored; and This STANDARD is not met as evidenced by: Based on observations, policy and procedure manual documentation and interviews with the staff it was determined the clinic failed to ensure all medications and supplies available for patient use were not expired and were stored safely. This had the potential to negatively affect all patients served by the clinic. Findings include: River Region Family Medicine Policy and Procedure Expired Sample Medications "All sample medications in the sample closets are inventoried monthly and all expired samples are placed in the facilities biohazard closet. They will then be picked up and signed for by authorized hospital personnel and taken to Elmore Community Hospital". A tour of the facility was conducted on 1/31/18 at 9:00 AM with Employee Identifier (EI) # 1, Assistant Manager, to observe medication and supply storage. During the tour each of the four halls were checked separately. Laurezi Hall: Exam Room # 1 1 - 16 oz bottle Hydrogen Peroxide opened and no open date on the bottle 1 - box tongue depressors expired 11/17 Exam Room # 2: 23 - tongue depressors expired 11/17 5 - packs cotton tipped applicators expired 11/17 Triage Room: 1 - single vial dose bottle of Ketorlac Tromethamine 60 mg (milligrams) / 2 ml (milliters) opened and not disposed of after use. Extra office with refrigerator on Laurenzi Hall: 2 - Repatha 140 mg/ml expired 12/17 2 - Toujeo 300 Units/ml expired 5/17 1- Toujeo 300 Units/ml expired 8/17 1 - Praluent Alirocumab 75 mg/ml expired 2/17 10 - 2 ml vials Iron Dextran 100 mg/ 2 ml expired 3/17. Lyons Hall: Exam Room # 1: 1 - Ipratropium Bromide Inhaler Solution 0.02% expired 10/12 1 - Ipratropium Bromide Inhaler Solution 0.02% expired 12/12 1 - open bottle Sodium Chloride Irrigation Solution expired 12/12 6 -Polylined Sterile Field packs expired 12/13 1 - Polylined Sterile Field pack expired 10/12 1 - pair purple Nitrile gloves opened 15 - packs Iodine pads expired 4/15 2 - 16 ounce bottles Hydrogen Peroxide open and no open date on bottle 1- bottle HemaScreen expired 5/13. Exam room # 2: 1 - 16 ounce bottle Hydrogen Peroxide open and no open date on bottle. Murphy's Hall: Exam Room # 5: 4 Packs - Iodine Swabs expired 10/17 Laboratory: 1- bottle 8.4% Sodium bicarbonate 84 mg/ml bottle open with no date opened 1 - bottle Nitrostat 0.4 mg/tablet expired 10/17. Kent Hall: Exam Room # 3: 6 - bottle 0.9% Sodium Chloride 250 cc (cubic centimeter) expired 3/16. Crash Cart Adult: No medications in crash cart EI # 2, Lab Tech, stated all the medications were expired and had been removed and new medications were ordered but had not received them. 2 - 3 ml syringes expired 12/17 1 1000 cc bag of Normal Saline (NS) expired 4/17 Crash Cart Pediatrics: No medications in crash cart EI # 2 stated all medications were expired and had been removed and new medications were ordered but had not received them. 2 - 3 ml syringes expired 12/17 1 - 1000 cc bag NS expired 4/17. Sample Medication Room: 1 -Flovent HFA (Hydrofluoroalkanes) 110 mcg (micrograms) expired 12/17 1 - Pennsaud 2% topical solution expired 12/17. Further review of the Sample Medication Room revealed no medication logs available for staff to sign out medications for facility patients. An interview was conducted on 2/1/18 at 1:15 PM with EI # 1, Assistant Manager, who confirmed the above mentioned findings and initiated a log for the Sample Medication Room. |