HospitalInspections.org

Based on observation, review of Pharmacy Policy #CMH/PHARM-24, manufacturer label review, and interview, the facility failed to follow hospital policy in that one multidose vial of Rocuronium Bromide and one multidose vial of Succinylcholine were stored at room temperature without being dated when removed from refrigeration. The practice occurred for one of two anesthesia carts located in surgery. The multidose dating policy not followed allowed for the medications to remain at room temperature exceeding manufacturer guidelines. A decrease in potency of the medications had the potential to affect the patient safety of a monthly average of 17.5 inpatient surgery patients and 60 outpatient surgery patients should there be physician orders for the medications to be administered. Findings follow:

A. A tour of Surgery was conducted on 10/25/10 at 1415. It was observed stored at room temperature on the Anesthesia Cart in Operating Room #1 one multidose vial of Rocuronium Bromide 100mg/ml and one multidose vial of Succinylcholine 200mg/10ml which had not been dated when removed from refrigeration.
B. Manufacturer label review on 10/25/10 at 1420 revealed when Rocuronium Bromide was removed from refrigeration the medication could be stored at room temperature for 60 days unopened and 30 days opened. Review of the label of Succinylcholine on 10/25/10 at 1420 revealed once the medication was removed from refrigeration, storage at room temperature should not exceed 14 days.
C. Pharmacy Policy #CMH/PHARM-24 was reviewed on 10/26/10 at 0830. The policy stated "Drugs requiring refrigeration for long term storage but stored at room temperature for short periods shall be dated when removed from refrigeration and destroyed when the recommended room temperature expiration date is reached."
D. The Director of Pharmacy was interviewed on 10/25/10 at 1425. The interview revealed hospital policy had not been followed in that the medications had not been dated when removed from refrigeration, therefore, there was no way to determine if the medications had exceeded the allowable time period for storage at room temperature.

Based on observation, review of Pharmacy Policy #CMH/PHARM-39, and interview, the facility failed to ensure outdated medications were not available for patient use in two (Post Anesthesia Care Unit, The Two Operation Room Anesthesia Carts) of six medication areas. The potential existed for a monthly average of 17.5 surgery patients and 60 outpatient surgery patients to receive these outdated medications, if physician ordered, which would affect patient safety. Findings follow:

A. A tour of Surgery and the Post Anesthesia Care Unit was conducted between 1415 and 1440 on 10/25/10. The following outdated medications were observed:
Post Anesthesia Care Unit
1) Five Lidocaine 2% Syringes located on Malignant Hypothermia Cart expired 10/01/10.
Anesthesia Carts
1) One Nimbex 20milligrams (mg)/10 milliliters (ml) expired 10/07/10;
2) Four Lidocaine HCl 2% and Epinephrine expired 07/01/10;
3) Two Hespan 500mg Intravenous Solution expired 09/10; and
4) One Lidocaine HCl 5% and Dextroise 7.5% ampoule expired 08/01/10.
B. Pharmacy Policy #CMH/PHARM-39 was reviewed on 10/26/10 at 0845. The policy stated "Outdated (expired), mislabeled, or otherwise unusable drugs and devices shall not be available for patient use."
C. An interview was conducted with the Director of Pharmacy at 1435 on 10/25/10. The interviewed revealed hospital policy had not been followed and the outdated medications were available for patient use.

Based on policy review, clinical record review, employee credential review and interview, it was determined the facility failed to establish procedures to ensure the effective delivery of nutritional care to patients. The failure was related to lack of policy review/revision; failure to screen all patients on admission and rescreen those not at risk on admission; failure to assess patients at nutritional risk; failure to follow up on patients receiving nothing by mouth (NPO) for three days or longer; and failure to ensure competency of nutrition staff who screen/assess patients and perform diet counseling. Four (#6, #7, #9 and #21) of 7 (#4 through #9 and #21) patients reviewed for nutritional care lacked evidence of nutrition care per policy. The failed practice had the potential to affect all patients admitted to the facility. Evidence follows:

A. Review of the Dietary Policies and Procedures revealed the absence of a cover sheet with signature and date of review by the RD (Registered Dietitian) or Dietary Director. The policies lacked evidence of review/revision to reflect current nutritional care for all patient in that they lacked policies related to orientation of employees; preventive maintenance; and infection control related to the receiving and storage of food.
B. The facility lacked a clearly defined nutritional screening and rescreening policy and failed to follow the nutrition screening and nutritional assessment policy as evidenced by:
1) Interview with the Dietary Director at 0930 on 10/26/10 revealed nursing screened all patients for nutritional risk on admission. The Dietary Director or Dietary Manager (DM) screened all patients referred to them by nursing within 24 hours. If the Dietary Director or the DM agreed the patients were at nutritional risk, information from the clinical record was faxed it to the RD for nutritional assessment. The assessment was placed in the clinical record within 72 hours of admission. The Dietary Director and DM did not screen any patients for nutritional risk unless referred by nursing.
a) The Nutritional Screening policy (May 2010) failed to clearly define that all patients were screened for nutritional risk by nursing on admission.
b) The Nutritional Screen portion of the Nursing Admission Assessment lacked a place to document when the patient was at risk or not at risk, making it unclear if the form was completed and the patient was not at risk, or it if was just not completed.
2) Review of the Obstetrics (OB) Nursing Admission Assessment revealed the lack of a nutritional screen section on the form.
3) Interview with Registered Nurse (RN) #4 at 1210 on 10/27/10 revealed nursing did not perform a nutritional screen on admission on the OB Unit.
4) The Nutritional Screening (May 2010) policy stated all patients who remained in house for 5 days would be rescreened by dietary and every patient receiving nothing by mouth (NPO) for 3 days would be flagged by dietary every three days.
a) Interview with the Dietary Director at 0845 on 10/27/10 revealed they did not rescreen because they lacked a method of tracking how long the patients were in the hospital to require nutritional rescreening.
b) Interview with the Dietary Director at 0845 on 10/27/10 revealed they lacked a method of tracking how long the patients remained on NPO status.
C. Review of employee credentials revealed a lack of documentation the Dietary Director and DM were competent to screen/assess patients for nutritional risk and perform diet counseling. The Dietary Director confirmed during interview at 0845 on 10/27/10 that neither she nor the DM had documented competencies for screening/assessing patients for nutritional risk or for dietary counseling, although they performed both functions.
E. Review of 7 (#4 through #9 and #21) clinical records for nutritional care documentation revealed 4 (#6, #7, #9 and #21) records lacked evidence of a nutritional screen per facility policy within 24 hours of admission, with a nutritional assessment if at risk, and rescreen every five days per facility policy.
1) Patient #6 was admitted on 10/17/10 with dysphagia, uncontrolled diabetes mellitus and dehydration (all were criteria for nutritional risk). The Nutritional Screen portion of the Nursing Admission Assessment was marked through and labeled N/A. There was no evidence in the record the RD was notified. During interview at 0950 on 10/26/10, RN #2 confirmed the lack of an initial nutritional screen, nutritional assessment, and nutritional rescreen after 5 days. The patient was still a patient on 10/26/10.
2) Patient #7 was admitted on 10/18/10 with uncontrolled diabetes mellitus and documented blood glucose level on admission of 453 mg/dl (criteria for nutritional risk). The section, "History of Uncontrolled Diabetes Mellitus" on the Nursing Admission Assessment was not checked. During interview at 1045 on 10/26/10, RN #3 confirmed the lack of an initial nutritional screen, nutritional assessment by the RD and nutritional rescreen after 5 days. The patient was still a patient on 10/26/10.
3) Patient #9 was not screened for nutritional risk per the nutritional risk criteria listed on the Nursing Admission Assessment.. The patient was admitted 10/14/10 with uncontrolled diabetes (criteria for nutritional risk.) The section "History of Uncontrolled Diabetes Mellitus" on the Nursing Admission Assessment was not checked. The patient was discharged on 10/25/10 with no evidence in the medical record of an initial nutritional screen, an assessment by the RD, or a rescreen in 5 days to determine nutritional status. The lack of documentation was confirmed by RN #4 during record review at 1125 on 10/27/10.
4) Patient #21 was admitted on 10/16/10 with a diagnosis of uncontrolled diabetes mellitus (criteria for nutrition risk). The section, "History of Uncontrolled Diabetes Mellitus" on the Nursing Admission Assessment was not checked. During interview at 1105 on 10/26/10, RN #1 confirmed the lack of an initial nutrition screen, a nutritional assessment by the RD and nutritional rescreen after 5 days. The patient was still a patient on 10/26/10.

Based on clinical record review and interview, it was determined the nursing staff failed to develop a plan of care that included goals for patient care for 1 of 1 (#17) obstetric patient. The failure to include goals for the provision of care had the potential to affect the outcome of patient care. The failed practice affected Patient #17 and had the potential to affect all patients admitted to Obstetrics. Findings follow:

A. Review of clinical record of Patient #17 was conducted on 10/27/10. The clinical record did not contain a care plan that included goals for patient care. The Clinical Pathway on the chart did not include goals for patient care.
B. Review of facility policy #CCMC/NUR-I-11 "Nursing Process Model" stated "A multidisciplinary team developed clinical pathways for most of the diagnosis treated at (facility named). When a patient is admitted a clinical pathway is initiated if one is developed for the patient's diagnosis. If a clinical pathway is not available, a nursing care plan is utilized." The policy did not stipulate goals for patient care must be included.
C. The findings were confirmed by interview with the Chief Nursing Officer on 10/27/10 at 1220 and he stated "The clinical pathway is the care plan" and confirmed the chart document did not include a goal for the provision of care.