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Based on record review and interview with staff member, the facility failed to develop a nursing care plan for 1 of 30 patients in the sample (Patient 2) for management of nausea and vomiting.

Findings include:

Patient 2 was admitted to the facility on 04/26/2018 for fever and neutropenia. On the morning of 05/02/2018 a record review was done. A review of the physician's order found prn orders for ativan (lorazepam) and zofran (ondansetron) for nausea/vomiting. A review of the care plan found the nursing care plan did not include interventions for the management of nausea/vomiting.

On 05/02/2018 at 9:39 AM an interview and concurrent record review was conducted with the Director of Patient Safety and Quality (DPSQ). The DPSQ acknowledged the patient has orders for ativan and zofran for nausea/vomiting. The DPSQ confirmed a care plan to manage the patient's nausea/vomiting was not developed.

Based on record review and interview with staff members, the facility failed to administer medications in accordance with physician orders for 1 of 30 sampled residents (Patient 2).

Findings include:

Patient 2 was admitted to the facility on 04/26/2018 for fever and neutropenia. A record review done on the morning of 05/02/2018 found a physician's order for zofran (ondansetron) 4 mg. every eight hours prn (first line for nausea/vomiting) and ativan (lorazepam) 0.5 mg. every six hours prn for nausea/vomiting, not responsive to ondansetron, do not use for sedation or mood. The review of the medication administration record (MAR) found documentation ativan was administered on 05/01/2018 at 3:17 PM. There was no documentation in the MAR that zofran was administered according to the physician's order. Subsequently, the MAR also documented two doses of ativan was administered on 05/02/2018 at 11:49 AM and at 6:14 PM.

On 05/02/2018 at 9:39 AM concurrent record review and interview was conducted with the Director of Patient Safety And Quality (DPSQ). The DPSQ confirmed the physician's order for prn use of zofran as first line for nausea/vomiting and ativan if not responsive to the zofran. The DPSQ also confirmed ativan was administered on 05/01/2018 at 3:17 PM. Inquired why the ativan was administered instead of the zofran as ordered by the physician. The DPSQ responded there may have been conversations regarding the use of ativan instead of zofran. The DPSQ reviewed the documentation by the nurse who administered the ativan; however, there was no documentation to address the usage of ativan instead of zofran. A review of the progress notes provided by the DPSQ for 05/01/2018 by the administering nurse found there was no documentation of the patient vomiting or complaints of nausea.

Based on observation and staff interviews, the facility failed to ensure correct labeling of medication and intravenous fluids to ensure outdated drugs/intravenous fluids would not be available for patient use.

Findings include:

1) On the afternoon of 05/01/2018 it was observed during a spot-check of medications in the Adult Intensive Care Unit, 2 multi-dose vials of Labetalol were located in individual patient medication bins. Both multi-dose vials had been opened and 2 of 2 labels did not have the beyond-use-date (BUD) marked on the label.

On the morning of 05/03/2018, an interview conducted with the Pharmacist in the Pharmacy department, confirmed that the hospital's policy was that the expiration date for multi-dose vials is 28 days from the date the vial is first punctured. Upon initial puncture, the revised expiration should be written on the vial. These were missing on both the multi-dose vials that were observed in the Adult Intensive Care Unit.

2) On the morning of 05/02/2018, an Intravenous Fluid (IV) bag of 250 cc Normal Saline solution and tubing was observed hanging on an IV pole in the medication room located on the Outpatient Adult Chemotherapy Unit. The IV bag had been punctured with the IV tubing and there was fluid in the tubing, ready for administration. There was no label on the IV bag to indicate what patient the IV solution was for or when it was prepared for administration. A Registered Nurse (RN) was interviewed who said the IV bag was prepared for a patient earlier in the morning who did not show up for the appointment. The RN agreed that any IV solution bags not immediately administered should be labeled and if not labeled should be discarded.

Based on observation, interview with staff members and review of the facility's policy and procedures the facility failed to ensure the full-time manager maintained policies for safe food handling and storage.

Findings include:

On 05/01/2018 at 10:25 PM observation of the kitchen was done with the Executive Chef and Kitchen Manager. Observation of the walk-in refrigerator found a tray of individualized servings of jello. The sticker affixed to the tray was documented with the preparation date of 04/24/2018. Inquired how long are prepared foods stored in the refrigerator. The Executive Chef responded 6 (six) days and commented there is more concern related to potentially hazardous foods. On 05/01/2018 at 11:55 AM, the facility provided a policy entitled Food Safety Product Labeling & Dating Guide. The contractor's standard notes the following: Advance production (food prepared for later use): Use within 5 days (for food safety reasons), if held at 40 degrees Fahrenheit (4 degrees centigrade) or below and if clearly marked with "use by date" (day or date product must be consumed, sold or discarded).

Observation of the meat refrigerator/freezer found two boxes of pork cubes defrosting on the shelf with a pan of potatoes covered with plastic wrap soaking in water below the defrosting meat. Upon the discovery of the pan of potatoes, the Executive Chef moved the pan. Observation of the reach-in refrigerator found a small metal container of cheese that was not labeled. Further observation found the flour bin with the scoop stored in the flour. The Kitchen Manager removed the scoop from the flour and confirmed the scoop should not be stored in the flour.

Observation of the ceiling found the ceiling tiles were splattered with dark brown to black substance, the tiles closer to the cooking area was more concentrated with the substance. There was one tile that was partially peeled, exposing the material under the first layer.

Based on observation and staff interview, the facility did not follow acceptable standards of practice by allowing staff's personal belongings to be brought into an operating suite, that is a restricted area requiring strict operating room attire.

Findings:

On 05/02/2018 at 9:30 AM, surgical practices for surgery scheduled were observed in Operating Room 9. A satchel/briefcase adjacent to the anesthesiologist was observed on the floor in operating Room 9.

On 05/02/2018 at 10:30 AM, the Operating Room Nurse Manager was interviewed as to why the satchel/briefcase was in the Operating Room. The Nurse Manager agreed to investigate why the briefcase was in the Operating Room.

On the morning of 05/03/2018, the Operating Room Nurse Manager confirmed the briefcase was a personal item that belonged to the anesthesiologist. The satchel/briefcase reportedly is brought in and out of the Operating Room (OR), taken out of the OR area and out of the facility. The OR Nurse Manager spoke with the anesthesiologist who said the anesthesiologist wipes down the satchel/briefcase before he enters the OR suite. The wipes used to disinfect the case was not specified.