HospitalInspections.org

Based on observation, staff interview, and policy review, the facility failed to ensure multi-dose vials had been discarded once beyond their use date, and failed to ensure a beyond use date had been placed on an opened multi-dose vial in 1 of 2 medication rooms sampled.

Findings include:

An observation of the general nursing unit's medication storage area was completed on 6/28/2017 at 8:10 AM with Licensed Practical Nurse (LPN) C. Inside the refrigerator was a multi-dose vial of regular insulin. The regular insulin had been opened and had a sticker placed on it that stated to discard as of 6/26/2017. LPN C confirmed the medication was beyond its use date and should have been discarded. Upon further inspection, a 20 milliliter vial of tuberculin was observed to have the cap removed. There was no identifying dates on the vial to indicate when it had been opened. LPN C confirmed the medication should have been dated once opened.

The hospital's policy entitled "Discard by date, after opening" dated 8/18/2010 with a revised date of 1/30/2017 was reviewed. The policy, under the Multi-Dose Vials section stated: "Will be dated when opened and initialed by staff opening vial. They will be discarded 30 days after opening." The policy, under Insulin-all types stated: "Will be dated when opened and initialed by staff opening vials. They will be discarded 30 days after opening."

Based on observation, staff interview, record review and policy review, the facility failed to ensure the administration of a medication in accordance with accepted standards of practice by failing to check the patient's name and date of birth prior to medication administration for 1 of 4 patients sampled (Patient #17), and failing to ensure implementation of facility policy for safe administration of medications related to obtaining verbal and telephone orders for 5 of 7 patients sampled (Patients #1, #2, #3, #4, and #9).

Findings include:

Licensed Practical Nurse (LPN) B was observed to gather medications for patient #17 on 6/27/2017 at 1:27 PM. LPN B gathered one medication tablet from the medication cart and stated it was the only medication the patient was to take at the scheduled time of 2:00 PM. She confirmed that while the Medication Administration Record (MAR) is kept electronically, a paper hard-copy is kept on each patient "just in case we need it." She then lifted a clipboard on top of the medication cart and showed multiple MARs for her patients. She placed the pill in a medication cup and walked to the patient's room. Upon entering the patient's room, she told the patient she was there to give her a medication. She then handed the pill cup to the resident who took the pill and swallowed it. LPN B then exited the room. She was asked what the appropriate procedure was for identifying a resident prior to giving them medication. She stated, "You are supposed to check their armband and confirm their name and date of birth." She confirmed that she had not done this prior to administering medication to the patient. She also confirmed that she had not taken the MAR, or anything else to verify the patient's name and date of birth with her to the room. She stated, "It is not something I ever think about since she's been here for a few weeks and I know who she is."

The policy titled "Medication Administration Rules" dated 1/1994 with a revised date of 1/30/2017 was reviewed. The policy, under section A (general principles), subsection D stated, "The nurse will verify the name and Medical Record or Date of Birth with patient's armband each time the patient receives medications. Verification will take place at the patient's bedside using the MAR or label as appropriate."




27622

#1 - On 6/26/17 at approximately 12:40pm, an intravenous (IV) antibiotic medication was observed to be hanging on the IV pole but not infusing. A bag of Normal Saline IV solution was infusing via an IV pump. The licensed nurse, Employee C, confirmed this observation and stated she forgot to unclamp the tubing for the medication to infuse. Review of the physician orders revealed the medication was scheduled to be administered at 8:00am. The Charge Nurse was made aware and was observed notifying the provider via telephone the antibiotic had not been given. A second phone call was made to the provider in the presence of Employee C and this surveyor to ask if should go ahead and infuse the dose. When she hung up the phone, she informed the nurse, in my presence, that the practitioner stated to not administer the dose scheduled for 8:00am and to administer the next dose at 4:00pm. The telephone verbal order was not written at the time the order was received, and the telephone verbal order was not read back to the provider on 6/26/17.
An additional review of Patient #1's medical record on 6/28/17 at approximately 9:20am documented a read back verbal telephone order on 6/26/17 at 1300 to hold 0800 dose of flagyl now and resume 1600 dose of flagyl 500mg IVP entered into the record by Employee D. This read back now documented in the medical record was not observed to have been conducted on 6/26/17 at 1300.

#2. Review of patient #2's medical record on 6/26/17 included a telephone order obtained on 6/24/17 with no documentation of a read back verification.

#3. Review of Patient #3's medical record conducted on 6/26/17 revealed the following: A phone order dated 6/24/17 from the ARNP for medication order and no indication of the telephone verbal order being read back, a verbal order dated 6/20/17 from the provider that included a medication order with no documentation of the verbal order being verified with a read back, a phone order dated 6/2/17 for a medication change with no read back verification, a telephone order dated 6/1/17 for initiation of a sleep medication with no read back, and a verbal order dated 5/30/17 for initiation of a medication without documentation of verification of the order received.

#4. Review of the medical record for patient #4 included a handwritten order by the nurse indicating it to be a standing order for a prescribed medication dated 6/13/17, a phone order obtained on 6/12/17 for a medication order, and a phone order for medication change obtained on 6/5/17, all of which failed to indicate a read back verification to ensure the accuracy of the physician orders.

#9. Review of the physician orders for patient #9 included a verbal order dated 6/27/17 for medication changes, a verbal order for medication changes on 6/25/17, medication changes on 6/21/17 written by the registered nurse, and phone orders on 6/20/17, none of which documented a read back verification.

On 6/26/17 at approximately 1:43, two licensed nurses were approached and asked what the procedure was for obtaining telephone and/or verbal orders from a practitioner. Licensed Practical Nurse (LPN), Employee E, stated she would write VORB when taking a phone order, but usually it is the Charge Nurse that gets the phone orders. LPN, Employee C, revealed she was not aware of the procedure, stated she does not take verbal or phone orders, and would consult with the Charge Nurse.

In interview with Registered Charge Nurse, Employee D, on 6/26/17 at 1:45pm she stated any phone order or verbal order should be documented as a "read back verbal telephone order" or "read back verbal order."

Review of facility's policy titled "Medication Administration Rules" Section gg. documented telephone orders were to be signed as "T.O./read back (T.O./R.B.) Dr. Name/Nurse Signature. Section hh. documented verbal orders were not recommended and if the doctor was present to give a verbal order, the nurse should make every effort to have the doctor write the order. In the circumstances where the physician was unable to write the order, the verbal order should be signed "V.O./repeated and verified (V.O.R.V.) Dr. Name/Nurse Signature"