HospitalInspections.org

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that medications were administered according to the standards of practice for 1 (Patient 8) of 2 patients observed for medication administration. Specifically, Patient 8's identification was not verified prior to the administration of breathing treatments.

Findings include:

A facility policy titled, "Medication Administration," revised 08/2023, revealed, "I. Patient Safety" included "A. Patient medications are administered using the five rights: right patient, right medication, right dose, right route and right time." The policy also indicated, "II Personnel Authorized to Administer Medications," which included "C. RN's [sic] [registered nurses]/LPNs [licensed practical nurses] and Respiratory Therapists may administer respiratory medications." The policy also indicated, "IX. Medication Management" included "B. Patient Identification," which revealed, "1. Prior to administering medication, patient identity will be validated using the patient's armband." The policy continued, "C. Medication Administration," which revealed, "1. Before administration, the individual administering the medication does the following," which included "a. Verifies that the medication selected matches the medication order and product label."

Patient 8's "History and Physical Examination," dated 08/24/2025, revealed the facility admitted the patient due to an acute exacerbation of chronic obstructive pulmonary disease (COPD) with hypoxia.

An observation on 08/27/25 at 4:10 PM revealed Respiratory Therapist (RT) #13 administered breathing treatments to Patient 8 without confirming the patient's identity. The observation revealed RT #13 did not have a computer with him to compare the medications with the medication administration record.

Patient 8's "Patient Progress Notes," dated 08/27/25 at 5:36 PM, revealed that on 08/27/25 at 4:10 PM, the patient received one inhaled dose of DuoNeb (a bronchodilator), 2.5 milligram (mg) albuterol sulfate and 0.5 mg ipratropium bromide per 3 milliliter (ml); and one nebulizer dose of Pulmicort (an inhaled corticosteroid), 0.25 mg budesonide.

During an interview on 08/27/25 at 4:20 PM, following the medication administration with Patient 8, RT #13 stated that respiratory therapy staff did not have a mobile computer on wheels, and if a therapist had more than one patient, they carried a paper with them that listed out the patients, the treatments, and the treatment times. RT #13 stated that if he had more than one patient, he checked their name and date of birth.

Based on observation, interview, facility policy review, and review of an endoscope's reprocessing manual, the facility failed to ensure infection control procedures were followed during 1 of 1 observation of a reusable endoscope being reprocessed. Specifically, Licensed Practical Nurse (LPN) #11 did not brush the used endoscope's buttons or channels, per the manual's instructions, prior to placing the endoscope in a reprocessing machine.

Findings include:

A facility policy titled, "High-Level Disinfection (HLD) Policy," dated 06/09/15, indicated, "Purpose: To establish standardized procedures for the high-level disinfection of reusable semi-critical medical devices in accordance with AORN [Association of Perioperative Registered Nurses] guidelines, ensuring patient and staff safety and reducing the risk of infection transmission."

An endoscope reprocessing manual provided by facility staff, revealed Section "5.3 Precleaning the endoscope and accessories" included "Preparation," "Wipe the insertion section," "Aspirate water," "Flushing the air/water channel with water and air," and "Flush the auxiliary water channel." The manual also revealed Section "5.5 Manually cleaning the endoscope and accessories" revealed that manual steps to clean the endoscope included "Clean the external surface," "Brush the channels," "Aspirate detergent solution through the instrument channel and the suction channel," "Flush the air/water channel with detergent solution," "Flush the auxiliary water channel with detergent solution," "Immerse the endoscope and accessories in detergent solution," "Remove detergent solution from all channels," and "Dry external surfaces.". The manual revealed, "Brush the channels," included a "Warning," which revealed, "Be sure to thoroughly brush the inside of the instrument channel, the instrument channel port, the suction channel, and the suction cylinder of the endoscope. Insufficient brushing may pose an infection control risk."

An observation of LPN #11 pre-cleaning a used reusable endoscope on 08/28/25 at 8:20 AM, revealed that after a procedure, the endoscope was transported in a container that was marked to indicate that it was dirty, to the reprocessing room. The endoscope was placed directly into a reprocessing machine. The endoscope's channels or buttons were not brushed prior to being placed in the reprocessing machine.

During an interview on 08/28/25 at 8:24 AM, LPN #11 stated that if an endoscope was soiled, he used a brush to clean the channels, and this was usually done before the endoscope was placed in the machine. LPN #11 stated that he did not do that on this endoscope because it was not a completed procedure, and the endoscope was not very soiled because the procedure was not completed. LPN #11 stated there were two endoscopes that were used for colonoscopies and two that were used for esophagogastroduodenoscopies (EGDs).

During an interview on 08/28/25 at 8:36 AM, Registered Nurse (RN) #10, who was the Surgery Manager, stated that representatives for the processing machine had provided endoscope processing education with the staff when the machine was replaced.

During an interview on 08/28/25 at 9:54 AM, RN #10 stated LPN #11 revealed that he had forgotten an endoscope brush for the endoscope processing that was observed. RN #10 stated that the process was to preclean, perform manual cleaning, and then disinfect used endoscopes.