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Based on hospital policy and procedure review, medical record reviews, staff and physician interviews the hospital's nursing staff failed to document verification of nasogastric (NG) tube placement for 1 of 1 patients (#8) sampled with an NG tube.

The findings include:

Review on 11/12/2013 of hospital policy "Nursing Process Standard" last review date 09/2011 revealed "...Assessment ...5. EFT (enteral tube feeding) may be administered via tubes inserted into the stomach (nasogastric tube) ...6. Nasogastric tube (NGT) placement is often performed by the bedside nurse. Tube placement is assessed by auscultation as well as by observing for the return of gastric contents. For NGT's which are inserted blindly, consult with the provider to determine need for radiographic confirmation (*) prior to initiation of enteral nutrition. Radiographic confirmation is suggested for those NGT's which are difficult to place. 7. Mark exit site on NGT and small bore tubes with permanent marker and reconfirm position every 12 hours...C. Maintenance Administration: ...2. Continuous ETF...a. determine patency and note placement of feeding tube b. aspirate gastric residual only through O/NGT...document volume aspirated. c. Maintain HOB at least 30" during feeding. d. Check residual every 4 hours while feeding. Document residual volume..."

Review on 11/12/2013 of a document provided by Nursing Management Staff, "Clinical Nursing Skills & Techniques" for NG tubes; Adapted from Perry, A.G., Potter, P.A. (2014) (8th ed.) St. Louis: Mosby, revealed "...nurses may insert small bore feeding tubes nasally or orally into the stomach at bedside without technological assistance (i.e. "blind" placement)...dislocation of feeding tubes from their intended position is a common occurrence...although all tubes should be marked to document correct position, tube dislocation may occur without any external evidence that the tube has moved from the intended position...following initial x-ray verification of proper tube position, the nurse must monitor the tube to ensure that the tip remains in the intended site...feeding tube position is checked at regular intervals (as often as every 4 hours) and before administering formula or medications through the tube...a reliable number of techniques can be used in combination to detect feeding tube dislocation. These...include marking and monitoring the external length of the tube and observing the appearance, volume, and pH of fluid aspirated through the tube...For intermittently tube-fed patients, test placement immediately before each feeding and before administering medications..."

Closed medical record review on 11/13/2013 for Patient #8 revealed an 82-year-old female admitted on 11/01/2012 with generalized tonic-clonic seizures and discharged on 02/15/2013. Review of the admitting physician's History & Physical (H&P) dictated 11/01/2012 at 0553 revealed "the patient (has) chronic kidney disease that has progressed to need for hemodialysis...she has a known seizure disorder being treated with Phenobarbital (medication for seizures)...On the way to dialysis today prior to receiving dialysis she developed another generalized tonic-clonic seizure. She was brought to the emergency room due to prolonged postictal (post seizure) phase...REVIEW OF SYSTEMS: unobtainable secondary to patient's still altered mental status post-ictally...PAST MEDICAL HISTORY: ...hypertension, hypothyroidism, chronic kidney disease, now on hemodialysis through right chest Perma-Cath (implanted devise)...history of B12 (vitamin) deficiency, schizophrenia, secondary hyperparathyroidism, anemia of chronic disease, senile dementia, pneumonia, funguria (fungus infection)...PHYSICAL EXAM: ...unable to participate with physical exam or answer questions...she was not following commands but did have plantar response to Babinski testing (neurological test) bilaterally and spontaneously moves all 4 extremities...ASSESSMENT: 82-year old woman with seizure disorder, end-stage renal disease, who had a seizure prior to dialysis today and now has a prolonged postictal phase. In addition , urinalysis suggestive of urinary tract infection....I have made her NPO (nothing by mouth) but we could advance this if she wakes up more. Obviously if she does not wake up by the timing of her medications tomorrow, will have to find IV (intravenous) alternatives at that point..."

Review of the Nurses Notes dated 11/10/2012 at 1745 revealed "NG (Naso Gastric) tube placed as ordered in right nare X4 (4 times) attempts by 4 different RN's. HR (heart rate) and BP (blood pressure) elevated as charted. HR also brady (low heart rate) to 49 (normal 60 - 100 beats/minute) during one attempt. MD aware." Continued review revealed no available documentation of NGT placement verification per policy and procedure. Continued review revealed no x-ray confirmation of correct NGT placement after insertion on 11/10/2012.

Continued review of the Nurses Notes dated 11/11/2012 at 1300 revealed "Pt (patient) received her PO (by mouth) med (medications) thru NGT. Suctioned her one time..." Review revealed no available documentation of NGT placement confirmation prior to medication administration per policy and procedure.

Continued review of the Nurses Notes dated 11/11/2012 at 2030 revealed "tube feeding increased to 60ml/hr..." Review revealed no nursing documentation of NGT verification on 11/11/2013 at 1900 through 0700 shift (12 hours no tube placement verification)

Continued review of the Nurses Notes dated 11/13/2012 at 1800 revealed "NGT removed and replaced with OGT (Oral Gastric Tube) ...pt tolerated with out distress..." Review revealed no available documentation of OGT placement confirmation per policy and procedure. Review revealed no x-ray confirmation of correct OGT placement after insertion on 11/13/2012.

Continued review of the Nurses Notes dated 11/15/2012 at 1101 revealed "TF (tube feeding) and OGT flushed for HD (hemodialysis) session." Review revealed no available documentation of OGT placement verification prior to flushing. Continued review revealed no nursing documentation of tube placement confirmation at the time OGT inserted on 11/13/2012 at 1800 through 11/15/2012 at 1101 (41 hours without confirming placement)when medication were administered via the tube.

Continued review of the Nurses Notes dated 11/18/2012 at 0330 revealed "patient pulled out NG tube from rt (right) nare...and was replaced." Continued review revealed no available documentation of NGT placement verification after insertion. Review revealed no x-ray confirmation of tube placement.

Review of the MAR (Medication Administration Record) on 11/18/2012 at 0507 revealed administration of Levothyroxine (Thyroid medication) 62.5 mcg VT (via tube). Review of Nurses notes revealed no verification of placement prior to medication administration.

Review of the MAR (Medication Administration Record) on 11/18/2012 at 0912 revealed administration of Zoloft (antidepressant) 50 mg VT, Keppra (antiseizure medication) 750 mg, Ocuvite (Vitamin A, C, & E/Lutein/Mineral) PO (by mouth), Acetaminophen (Tylenol) 500 mg VT. Review of the Nurses Notes revealed no confirmation of NGT placement prior to medication administration.

Review of an abdominal x-ray report dated 11/18/2012 at 1433 revealed "...Findings: NG tube extends into the right lung base. Removal recommended...Impression: NG tube in right lung base. Removal recommended. Comment: Discussed with Dr. (name) at 5:00pm."

Continued review of the nurse's notes revealed no available documentation of NGT removal by the nursing staff. Continued review revealed no documentation of discontinuation of the continuous tube feedings.

Review of the Respiratory Therapy (RT) notes dated 11/18/2012 at 1558 revealed "O2 (oxygen) SAT (saturation) (oxygen in blood): 100%..." At 1600 "O2 SAT: 100%."

Review of the Nurses Notes dated 11/18/2012 at 1700 revealed "Pt pull(ed) out NG tube. Reinsertion done after explaining procedure to pt. Pt tolerated procedure well. Chest x-ray done to verify placement." Review revealed no nursing documentation of NGT placement verification after insertion.

Review of the x-ray reports from 11/18/2012 at 1700 through 11/24/2012 revealed no x-ray reports for NGT placement verification for 11/18/2012 at 1700. (Confirmed with Nursing Administration the only x-ray completed on 11/18/2012 was at 1433).

Continued review of the Nurses Notes dated 11/18/2012 at 2000 revealed "RN reported that patient pulled out NG tube from Rt nare today and attempted to insert NG tube but was unsuccessful. RN asked if NG tube can be inserted by oncoming nurse. RN stated that if unsuccessful in placing NG tube to let on-call MD (medical doctor) know; will pass on to next shift..."

Review of the Intake and Output (I & O) record revealed on 11/18/2012 - 0700 - 1500 (end of shift totals) a total of 320 ml (milliliters) of tube feeding and 240 ml of tube feeding flush was administered.

Review of the I & O record dated 11/18/2012 - 1501 - 2300 (end of shift totals) tube feeding and tube feeding flushes are documented as "0.00"

Continued review of nurses notes on 11/19/2012 at 0125 revealed "#14 NGT inserted into R (right) nare, tolerated well, secure and tube feeds resumed at 40 ml/hr (hour) cont (continuous) infusion, hob (head of bed) elevated..." Review revealed no nursing documentation of NGT placement verification or residual amount after insertion or prior to tube feeding initiation. Continued review revealed no abdominal x-ray confirmation of correct tube placement on 11/19/2012 at 0125.

Interview on 11/13/2013 at 1000 with Nursing Management staff revealed "our Nursing Process Standard for Enteral feedings is in the process of being revised but the most current one is the one with the last review date of 09/2011...we also use the Mosby Clinical Skills book as our policy practice standards..."

Interview on 11/13/2013 at 1345 with RN #1 revealed "...when we insert a new NG tube we determine placement by auscultation over the stomach and listen for the 'swoosh' of air and aspirate for any stomach contents. The tube is labeled with numbers so you can mark and identify the placement of the tube. The number helps you assess whether the tube has moved or still in place. Once the tube is secure if we have had any difficulty inserting the tube we verify placement by getting an x-ray. Yes I did tube feeding for this patient when she returned from dialysis. I do not see any documentation of my assessment for placement. I do not see any documentation of where the tube was marked and at what placement level I should have looked for...it's marked to help you identify if the tube has moved out of the stomach...if the tube is out of the stomach there's risk of aspiration...I should have noted in my notes that I verified placement and identified the markings...I'm not sure where the person who put the tube in would have documented the number for insertion depth but it should be documented. We check residual prior to restarting the feeding when the patient returns from Dialysis but I do not see the documentation for tube verification or residual amount on the two days I cared for the patient..." Interview confirmed there is no documentation of the verification of the nasogastric tube placement.

Interview on 11/13/2013 at 1450 with RN #2 revealed "when the NG tube is inserted it is standard to get an x-ray to validate placement then we flush and check residual to determine placement...we mark the number on the tube and place the clasp that we anchor the tube with at the marking...I do not see the number marked in the chart...I have never documented it in the chart...we should always check for placement and residual prior to medication administration and bolus feed...there is no documentation of the residual amounts..." Interview confirmed the notation of tube placement depth was not documented in the chart prior to initiation of the tube feeding and medication administration.

Interview on 11/13/2013 at 1145 with the Nurse Manager revealed "NG tubes are inserted by the nurses at the bedside and once inserted they should aspirate the contents, check for air sounds with stethoscope over the stomach, and confirm by x-ray after calling the physician. It should be documented in the chart that placement was verified, the depth of the tube should be marked so the next nurse can identify if the tube has moved since insertion...all of this should be documented in the chart...with each bolus feed and each flush verification of tube placement, depth marking, and residual should be documented in the chart. this patient was on continuous tube feedings...When the patient is on continuous tube feeds they still are to flush the tube and with every flush and with every medication administration it should be documented that placement was verified and depth marking on the tube had not changed...Yes I saw in this chart the verification was not consistently documented and the depth marking was not documented in the chart...if it took 4 attempts before a tube was successfully placed...I would definitely expect an x-ray to be done to verify placement." Interview confirmed the staff failed to document verification of NG tube placement.

Interview on 11/14/2013 at 0910 with Physician #1 revealed "...After insertion of NG tube the placement should be verified with an abdominal x-ray..." Interview confirmed abdominal x-rays should be done to verify placement after insertion of an NG tube.

Based upon policy and procedure review, observations during tours, and staff interviews, the hospital staff failed to ensure floor stock medications were not expired by ensuring insulin multi-dose vials were initialed and dated when opened and discarded within 28-days after opening for 2 of 4 units toured (#1 and #2).

The findings include:

Review of hospital policy, "Use of Multi-Dose Vials of Parenteral Medication in Patient Care Areas", revision date August 2012 revealed, "PURPOSE To provide outlines for the management of multi-dose vials of parenteral medications in patient care areas. Guidelines...F. As a standard, the only recognized multi-dose vials are insulins...PROCEDURES A. Recognized Multi-Dose vials usage guideline: 1. Vials must be labeled when entered with: a. Expiration date according to this policy. b. Initials of the person that entered/reconstituted the vial. B...1. Insulin multi-dose vials, of any form, must be discarded within twenty-eight (28) days if entering the vial..."

1. Observation during tour of Unit #1 on November 15, 2013 at 1030 revealed two (2) opened insulin vials with smeared and illegible handwritten initials of the person that opened the vials and opened dates on the vial labels.

2. Observation during tour of Unit #2 on November 15, 2013 at 1130 revealed one (1) opened insulin vial without a handwritten opened date on the vial label.

Interviews conducted during tour on November 15, 2013 at 1030 and at 1130 respectively, with nursing management staff confirmed the opened insulin vials had no handwritten opened date, nor a legible hand written date on the vial label. Interviews confirmed the nursing staff inability to determine whether the insulin vials had been opened for greater than twenty-eight (28) days. Interviews confirmed the nursing staff failed to follow hospital policy.

Interview conducted on November 18, 2013 at 1350 with the Director of Pharmacy revealed the pharmacy technicians monitored the nursing units once a month for expired vials. Interview further revealed if expired vials were found, the expired vials were to be sent back to pharmacy, discarded, and a new vial was sent to the unit. Interview confirmed the nursing staff failed to discard opened insulin vials with illegible handwritten initials and opened dates written on the label(s) or not dated when opened by the nursing staff.

Based on hospital job descriptions, observations during tour, and staff interviews the hospital's staff failed to maintain supplies in a manner to ensure an acceptable level of safety and quality on 2 of 4 nursing units toured.

The findings include:

Review of the job description "Patient Supply Associate II" dated 06/27/2005 revealed "...Periodically inspect cart to ensure all items are in assigned locations; remove, replace and report any expired or sterile items with broken packaging..."

Review on 11/14/2013 of an e-mail provided by the hospital Pharmacist dated 11/14/2013 at 1413 revealed "Subject: Isopropyl Alcohol Expiry. From: (name) Regulatory Systems Manager/Microbiologist (name of company)" revealed "I received your inquiry today on the phone regarding the expiration date of 70% Isopropyl Alcohol, manufactured at (name of company). As these products are considered over-the-counter drugs by the FDA, we are required to designate an expiration date to the product - in this case - of 2 years from the date of manufacture. However, once the product has been opened, we do not have a new expiration date for the product, nor documentation to substantiate a different expiration date...Typically, we recommend that the customer set an internal expiration date of their choosing, once the bottle is opened, to ensure that the product used is still at the optimum level of potency..."

1. Observations during tour on 11/14/2013 at 1110 of the hospital's Medical/Oncology 5-3 Unit revealed a 40 bed unit with a current census of 39 patients. Observation during tour of the clean supply storage room revealed two (2) 16 ounces (oz) bottles of Betadine (antiseptic) Solution with expiration dates of 10/2012 (1 year and 13 days expired) and 09/2013 (44 days expired). Continued observation of the sterile supplies shelves revealed two (2) Sterile Suture Removal kits that were opened. Continued observation revealed one (1) opened bottle of 16 oz 70% Isopropyl Alcohol . (Unable to validate sterility and integrity of solution.)

Interview with the nursing staff and nursing management staff during the tour confirmed the Betadine Solution was outdated and the sterile suture removal kits were open and had been contaminated "probably because the staff opened them to remove the scissors and instead of discarding the kit they put the opened kit back on the shelf with the sterile supplies." Interview during the tour revealed "we're not sure why we have opened bottles of Alcohol on the supply shelves...not sure when they were opened or how long they have been opened...we can not guarantee they are not contaminated..." Interview confirmed the Betadine was outdated and the suture removal kits were contaminated sterile supplies.

2. Observation during tour on 11/14/2013 at 1205 of the hospital's Mother/Baby/Gynecologic 4-3 Unit revealed a 40 bed mother/baby unit with a census of 41 (21 adult patients and 20 newborns). Observation during tour of the Medication Storage Area revealed three (3) opened bottles of 16 oz 70% Isopropyl Alcohol (Unable to validate sterility and integrity of solution). Continued observation revealed two (2) Hemocult slides (tests blood in stool) with expiration dates of 09/2011 (2 years and 44 days expired) and 09/2013 (44 days expired). Continued observation in the clean/sterile supply room revealed one (1) Central Line Dressing Kit with an expiration date of 04/2013 (6 months and 13 days expired).

Interview with nursing staff and the nursing management staff during the tour confirmed the Hemocult slides and central line dressing kit were outdated. Interview confirmed the alcohol bottles had been opened and staff could not identify how long the bottles had been opened. Interview during the tour revealed "materiel's management rotates the sterile supplies in the clean/sterile supply room but the nurses check for outdates at the medication stations...we check them periodically but I do not have a schedule or a log that shows when or how often we check supplies for outdates..." Interview confirmed the Hemocult supplies and the central line dressing kit were outdated and how long the large volume alcohol had been open for use could not be determined.

Interview on 11/14/2013 at 1355 with Nursing Managment staff revealed "materiels management department is responsible for rotating supplies and removing outdated supplies from the units but we do not have a policy and procedure that addresses this, it is listed as a responsibility in the materiel management staff's job description."

Based on Centers for Disease Control and Prevention (CDC) Healthcare Infection Control Practices Advisory Committee (HICPAC) Guidelines review, hospital educational flyer review, policy reviews, observations during tour, and staff interviews, the hospital's infection control officer failed to develop an effective system for identifying, reporting, investigating, and controlling infections within the Operating Room (OR) suite by failing to ensure staff maintained the sterility of Intravenous (IV) in-line stop-cock access ports before medication administration and to ensure OR staff did not dangle surgical mask (Personal Protective Equipment) around their neck.

The findings include:

1. Review on 11/15/2013 of the CDC HICPAC "Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011" found at www.cdc.gov/hicpac/BSI/BSI-guidelines-2011.html revealed "...Needleless Intravascular Catheter Systems ...4. Minimize contamination risk by scrubbing the access port with an appropriate antiseptic (Chlorhexidine, Povidone iodine, an iodophor, or 70% alcohol) and accessing the port only with sterile devices...."

Review on 11/14/2013 of an educational flyer "SAVE That Line!" provided by nursing management staff revealed "...ASEPTIC TECHNIQUE During catheter insertion and care VIGOROUS FRICTION TO HUBS Vigorous friction with alcohol wherever you 'make or break a connection' to give medications, flush, or change tubing an injection port or add on device ..."

Review of current hospital policy "Peripheral Intravenous...." approved 02/22/2012, revealed "...POLICY: ...10. IV Administration Set Change Times ...(d) Needleless connector caps * To prevent the entry of microorganisms into the vascular system, the cap should be aseptically cleansed for 15 seconds and allowed to dry for 15 seconds with an alcohol swab or CHG immediately prior to use. ..."

Observation during a surgical procedure on 11/14/2013 at 1100-1139 for Patient #15 in OR #2, observed a Certified Registered Nurse Anesthetist (CRNA #1) and Student Registered Nurse Anesthetist (SRNA #1) administer multiple medications (Lidocaine, Propofol, Fentanyl, Versed, and Phenylephrine) intravenously via a multi-port in-line stop cock to Patient #15 intra-operative. Observation revealed the multi-port in-line stop cock was not located on a sterile field. Observation failed to observe the CRNA and SRNA cleanse with vigorous friction the in-line stop cock ports with an appropriate antiseptic (i.e. CHG, alcohol) for a minimum of 15 seconds prior to each medication administration. Further observation revealed upon completion of the procedure the CRNA removed all medication syringes from the multi-port in-line stop cock and placed red caps onto the ports without aseptically cleansing the ports. Observation confirmed the CRNA and SRNA failed to follow CDC guidelines and hospital policy.

Interview on 11/14/2013 at 1155 with CRNA #1 revealed "I do not routinely use alcohol pads on the ports in between medication administrations due to so many medications." Interview confirmed the CRNA failed to follow hospital policy.

Interview on 11/04/2013 at 1200 with SRNA #1 revealed he did not use an appropriate antiseptic to disinfect the in-line stop cock ports prior to medication administrations during Patient #15's surgical procedure. Interview confirmed SRNA #1 failed to follow hospital policy.

Interview on 11/14/2013 at 1205 with the Director of Surgical Services revealed staff should disinfect IV line ports and in-line stop cock access ports prior to administering medications to patients in order to decrease the potential for contamination. Interview confirmed the CRNA and SRNA failed to follow hospital policy.

2. Review of current hospital policy "Attire in the Operating Room" approved 09/18/2013, revealed "...POLICY ...10. ...* Masks should not dangle around the neck. * Masks must be removed when leaving the department. ..."

Observation during tour of the hospital's main OR Suite on 11/14/2013 at 1036 revealed OR Staff #1, #2, #3, and #4 with surgical masks dangling around their necks. Further observation at 1045 revealed OR Staff #5 entered the main OR Suite from a hallway (not located in department) with a surgical mask dangling from the neck. Observation confirmed the OR staff failed to follow hospital policy.

Interview on 11/14/2013 at 1205 with the Director of Surgical Services revealed staff should not be letting their surgical masks hang around the neck. Interview revealed "the policy states no dangling." Interview confirmed the OR staff failed to follow hospital policy.

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