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Based on observations, document review and interview nursing staff failed to prepare medications in a manner to reduce the risk of infection for two of four patients observed during medication administration. (Patients #10 and Patient #13)

The findings included:

1. An observation was conducted on October 30, 2013 at approximately 8:44 a.m. through 9:21 a.m., with Staff #20. Staff #20 obtained five injectable medications (Levothyroxine Sodium, Metoprolol Tartate, Famotidine, Furosemide and Lovenox) from the facility's automated medication dispensing system for Patient #10. Patient #10 was on droplet precautions. Once in Patient #10's room Staff #20 set the medication vials on a counter in the patient's room. Staff #20 administered the pre-filled syringe of Lovenox. Staff #20 prepared the Famotidine by removing the flip top of the vial exposing the vial's septum. Staff #20 did not clean the septum prior to inserting the syringe.

After administering the Famotidine, Staff #20 handled the calibrated collection system attached to Patient #10's urine collection system. Staff #20 tilted the closed calibrated system upward to empty the urine into the main urine collection system. Staff #20 reported the need to check the patient's urine output in order to determine if the Furosemide was working. Staff #20 did not change gloves before preparing the Furosemide for administration. Staff #20 removed the flip top from the Furosemide vial and without cleaning the vial's septum inserted the syringe. Staff #20 prepared Patient #10's Metoprolol Tartate in the same manner without cleaning the vial's septum. After checking Patient #10's medication administration record (MAR) Staff #10 decided to wait before administering the Metoprolol Tartate. Staff #20 removed the glove from his/her right hand and prepared a label for the syringe. Staff #20 placed another glove on his/her right hand without performing hand hygiene and using the unchanged glove on his/her left hand. Staff #20 placed the labeled syringe and the vial of Metoprolol Tartate towards the back corner of the counter in the patient's room.

Staff #20 reported the Levothyroxine Sodium was a powder and needed to be reconstituted with 0.9 % Sodium Chloride. Staff #20 removed the flip top from the vial of 0.9 % Sodium Chloride and from the vial of Levothyroxine Sodium. Staff #20 did not clean the septum of the 0.9 % Sodium Chloride vial prior to inserting the syringe to withdraw the required amount. Staff #20 using the same syringe, injected the 0.9 % Sodium Chloride into the Levothyroxine Sodium vial. Staff #20 reconstituted the Levothyroxine Sodium by gentling shaking the vial. Once mixed Staff #20 used the same syringe to withdraw the reconstituted Levothyroxine Sodium for administration to Patient #10. Staff #20 did not clean the septum of the Levothyroxine Sodium vial prior to injecting the 0.9% Sodium Chloride or prior to withdrawing the reconstituted Levothyroxine Sodium for administration. Patient #10's medications were administered through a port of his/her intravenous line except for the Lovenox, which was injected into the patient's abdomen.

[According to www.drugs.com : Levothyroxine is used to treat an underactive thyroid (hypothyroidism). It is a man-made substance that replaces the natural substance (thyroid hormone) that is normally produced by the thyroid gland. Famotidine (pepcid) is a histamine-2 blocker [that] works by decreasing the amount of acid the stomach produces. Furosemide is a loop diuretic (water pill) that prevents your body from absorbing too much salt, allowing the salt to instead be passed in your urine. Furosemide treats fluid retention (edema). Metoprolol is a beta-blocker that affects the heart and circulation (blood flow through arteries and veins). Metoprolol is used to treat angina (chest pain) and hypertension (high blood pressure). Lovenox (enoxaparin) is an anticoagulant that helps prevent the formation of blood clots.]


2. An observation was conducted on October 30, 2013 at 11:50 a.m., with Staff #21. Staff #21 prepared an intravenous antibiotic (Zosyn) for Patient #13. Staff #21 retrieved a vial of Zosyn from the facility's automated medication dispensing system along with a 100 ml (milliliter) bag of normal saline. Staff #21 removed the flip top from the vial of Zosyn, attached a connector device to the vial and attached the 100 ml bag of normal saline to the other end of the connector. Staff #21 did not clean the septum of the Zosyn vial prior to attaching the connector. Staff #21 squeezed the fluid from the 100 ml bag of normal saline through the connector into the Zosyn vial. After four attempts to reconstitute the Zosyn, Staff #21 removed the connector from the Zosyn vial. On removing the connector, the top of the vial (metal ring encircling the septum) separated from the vial. Staff #21 pressed the top back down on the vial, cleaned the septum with an alcohol pad. When Staff #21 attempted to withdraw the reconstituted Zosyn by tilting the vial, the top separated from the vial and Staff #21 pressed the top back in place with a gloved finger. Staff #21 did not re-wipe the vial's septum prior to inserting the syringe into the vial. Staff #21 injected the reconstituted Zosyn into the 100 ml bag of normal saline. Staff #21 entered Patient #13's room after identifying the patient. Staff #21 without having gloves on, cleaned a port on Patient #13's IV line, flushed the IV line and started the administration of the Zosyn.

[According to www.drugs.com Zosyn contains a combination of piperacillin and tazobactam. Piperacillin and tazobactam are penicillin antibiotics that fight bacteria in the body.]
An interview was conducted on October 30, 2013 at approximately 4:44 p.m., Staff #2 and Staff #35. A request was made for the facility's policy and procedure for medication administration.

Review of the facility's policy titled "Medication Administration" did not provide details for the preparation of medication.

An interview was conducted on October 31, 2013 at approximately 10:01 a.m., with Staff #2 and Staff #26. A request was made for the basic instructions of medication preparation or the standard/best practice information utilized by the facility. Staff #2, Staff #26, and the surveyor reviewed the facility's "Skills Competency Checklist" for withdrawing medications form a vial. "Skills Competency Checklist" read "... Removes the metal or plastic cap from the top of the vial (if present) without touching the rubber stopper [septum]; Cleans the rubber stoppers of the vials using a separate alcohol swab for each vial ..." The surveyor informed Staff #2 and Staff #26 regarding the findings obtained during observations. Staff #26 stated, "No, I recently reviewed this with staff. They know the vial septum is not sterile and needs to be cleaned." Staff #26 reported it was not the facility's policy to remove one glove. Staff #2 and Staff #26 reported the staff person should have removed both gloves and performed hand hygiene prior to putting on a new set of gloves. Staff #26 verified once the staff person touched the urine collection system, their gloves should have been removed then hand hygiene performed before putting on new gloves and preparing medications for administration.

Based on document review and interview the facility's utilization review committee failed to incorporate review of their prospective payment system (PPS) unit's outlier cases.

The findings included:

An interview and review of the facility's Utilization Review (UR) Committee's plan and meeting minutes was conducted on November 1, 2013 from 8:30 a.m. through 8:59 a.m., with Staff #2 and Staff #36. Staff #36 reported the data from facility's prospective payment system (PPS) unit was not incorporated into the UR data. Staff #36 stated, "I think they do their own, but they are not represented on the UR committee." Staff #36 reported he/she was not sure if the PPS unit's data was forwarded to quality or what happened to ensure information from outlier cases was a part of the overall facility review. Staff #2 stated, "I don't think their [PPS unit's] data is reviewed in quality."

Based upon observations & discussions there are open or compromised penetrations above the Fire Doors in the Corridors which will allow the passage of smoke & flames from one smoke compartment to another.

Findings include that November 12, 2013 between the hours of 08:30 hours and 16:30 hours, accompanied by the Facilities Director of Support Operations, the following items were noted: Observed open or compromised penetrations in the walls above the Fire Doors that separate the elevator Lobby and the Nurses Stations in the North & South wing on the 3rd & 4th floors; open or compromised penetrations in the walls in the various IT closets and Electrical rooms on the 3rd, 4th and 5th floors. This finding has the potential to affect 60% of the occupants.

The Facilities Director of Support Operations confirmed these findings.

Findings include that November 14, 2013 between the hours of 13:00 hours and 18:00 hours, accompanied by the Facilities Director of Support Operations, the following items were noted: Observed open or compromised penetrations in the walls above the Fire Doors that separate the elevator Lobby and the Nurses Stations in the North & South wing on the 2nd floor; open or compromised penetrations in the walls in the various IT closets and Electrical rooms on the 2nd & 1st floors and in the Materials Management Storage room on the 1st floor. This finding has the potential to affect 40% of the occupants.

The Facilities Director of Support Operations confirmed these findings.


Based upon observations, the sprinkler system installation and maintenance accessibility was not in accordance with NFPA 13.
Findings include that November 12, 2013 between the hours of 08:30 hours and 16:30 hours, accompanied by the Facilities Director of Support Operations, the following item was noted: Observed missing sprinkler head coverage under duct work in the mechanical rooms on the 5th floor North and South Wings This finding has the potential to affect 60% of the occupants.

The Facilities Director of Support Operations confirmed these findings.

Findings include that November 14, 2013 between the hours of 13:00 hours and 18:00 hours, accompanied by the Facilities Director of Support Operations, the following items were noted: Observed missing sprinkler head coverage under duct work in the mechanical room of the C U P building near the overhead door by the Fire Pump; missing sprinkler heads in some closets on the 2nd floor in the Family Maternity Center. This finding has the potential to affect 40% of the occupants.

The Facilities Director of Support Operations confirmed these findings.

Based on observations and interview the facility failed to implement a system to ensure staff practiced infection reducing behaviors as evidenced as:
1. Nursing staff failed to change gloves when moving between dirty and clean task.
2. Nursing staff fail to wear appropriate personal protective equipment (PPE)
3. Staff failed to ensure mattress/pads surfaces were intact and could be disinfected between patients.

The findings included:

1. Observations were conducted on October 30, 2013 at approximately 8:44 a.m. through 9:21 a.m., with Staff #20. Staff #20 failed to change gloves after handling the patient's urine collection system and prior to preparation of medications. Staff #20 removed the glove from one hand to prepare a label for a syringe of medication that would be administered at a later time. Staff #20 did not perform hand hygiene after removing the glove from his/her right hand or prior to putting a new glove on his/her right hand. Staff #20 used the same glove on his/her left hand throughout the observation from the initial preparation of medication, to handling the patient's urine collection system, obtaining a new glove for his/her right hand, returning to medication preparation and performing a wound care.

2. An observation was conducted on October 30, 2013 at approximately 11:20 a.m. through 11:45 a.m., with Staff #34, during blood glucose checks. Staff #34 performed the glucose testing for Patient #34 without wearing gloves and after completion of the testing, removed the strip with the blood sample from the glucometer with his/her bare hands. Staff #34 then put on gloves to clean the glucometer and case. Staff #34 continued performing the glucose testing for Patients #5 and #8 without wearing gloves. Staff #34 removed the strip with the blood sample from the glucometer with his/her bare hands after completing each glucose testing. Staff #34 did not put on gloves until cleaning the glucometer and case.

An observation was conducted on October 30, 2013 at 11:50 a.m., with Staff #21. Staff #21 prepared an intravenous antibiotic (Zosyn) for Patient #13. Staff #21 entered Patient #13's room after identifying the patient. Staff #21 without having gloves on, cleaned a port on Patient #13's IV line, flushed the IV line and started the administration of the Zosyn.

An interview was conducted on October 31, 2013 at approximately 10:01 a.m., with Staff #2 and Staff #26. The surveyor informed Staff #2 and Staff #26 regarding the findings during observations. Staff #26 reported it was not the facility's policy to remove one glove. Staff #2 and Staff #26 reported the staff person should have removed both gloves and performed hand hygiene prior to putting on a new set of gloves. Staff #26 verified once the staff person touched the urine collection system, their gloves should have been removed then hand hygiene performed before putting on new gloves and preparing medications for administration or wound care. Staff #2 and Staff #26 reported that staff should wear gloves any time there was a risk related to exposure from blood and or body fluids.


3. An observation and interview was conducted on October 30, 2013 at approximately 8:30 a.m., with Staff #4. The observation revealed tape residue on the mattress in Exam Room #4. Staff #4 reported housekeeping had "just cleaned the bed."

Observations conducted on October 31, 2013 at approximately 1:30 p.m., with Staff #37 and Staff #38 revealed the pad on the radiology table (Room #6) had tears at all four corners. Staff #37 acknowledged the non-intact surface prevented disinfection of the pad between patients. The observation revealed a sponge-like foam positioning device in Room #5. Staff #38 acknowledged the device could not be cleaned between patients.

Observations and interviews were conducted on October 31, 2013 at 1:44 p.m., with Staff #37, Staff #38, Staff #39 and Staff #40. The observations revealed the white head rest in Room #2 did not have an intact surface. Staff #37 had the device removed from the room. Staff #37 and Staff #38 reported it was the responsibility of the direct care staff as well as the managers to ensure items utilized in direct patient care could be disinfected between patients.