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Based on observations, interview, and review of standards of practices, it was determined the facility failed to ensure the nursing staff administered medications safely in 2 of 2 observations of medication administration. This had the potential to negatively affect all patients served by this facility.

Findings include:

Potter-Perry
Fundamentals of Nursing, 6th Edition
Unit VI - Medication Administration
page 852

Critical Decision Point: Medications that need to be broken to administer half the dose can be broken, using a gloved hand, or cut with a pill-splitting device. Tablets that are to be broken in half must be prescored. Prescored tablets are identified by a manufactured line that transverses the center of the tablet.

Delmar Nurse's Drug Handbook, 2010
Section 5:
Nursing Considerations for Nursing Process: Implementation of the Administration of Medications by Different Routes
page 3

Tablets/Capsules
1. Unless a tablet is scored, it should never be broken to adjust dosage. Breaking can cause incorrect dosage, gastrointestinal (GI) irritation, or destruction of the drug in a incompatible pH...

An observation of medication administration was conducted with Employee Identifer # (EI) 5, the Licensed Practical Nurse (LPN) on 8/15/12 at 8:50 AM to Patient Identifer (PI) # 1. EI # 5 obtained a Namenda 10 milligrams (mg) from the medication system and placed the Namenda in the pill splitter to obtain the 5 mg dosage the patient was to receive. The surveyor observed no manufacturer's scoring line for the tablet. The surveyor asked EI # 5 if the tablet was scored and the response was, "No". The surveyor observed EI # 5 administer the 1/2 tablet of Namenda to PI # 2.


An observation of medication administration was conducted with EI # 5 on 8/15/12 at 9:10 AM to PI # 2. EI # 5 obtained a Toprol 50 mg from the medication system and placed the scored Toprol in the pill splitter to obtain the 12.5 mg the patient was to receive. EI # 5 split the tablet one time along the score line. EI # 5 then took the 1/2 tablet and split it into 1/4 tablet. The surveyor asked if the tablet had 2 scores and the response was, "no just one". The surveyor observed EI # 5 administer the 1/4 tablet of Toprol to PI # 2.

An interview was conducted with EI # 6, the Director of Nurses on 8/15/12 at 2:30 PM. The surveyor requested a policy on the splitting of medications and the response was, "There is not one here."

An interview was conducted on 8/16/12 at 8:45 AM with EI # 3, the Pharmacist. The surveyor asked if it was acceptable to split an unscored tablet or split a tablet in 1/4. The response was, "They do it every where I have ever been".

Based on observations, interview, and review of standards of practices, it was determined the pharmacist failed to ensure the nursing staff administered medications safely in 2 of 2 observations of medication administration. This had the potential to negatively affect all patients served by this facility.

Findings include:

Potter-Perry
Fundamentals of Nursing, 6th Edition
Unit VI - Medication Administration
page 852

Critical Decision Point: Medications that need to be broken to administer half the dose can be broken, using a gloved hand, or cut with a pill-splitting device. Tablets that are to be broken in half must be prescored. Prescored tablets are identified by a manufactured line that transverses the center of the tablet.

Delmar Nurse's Drug Handbook, 2010
Section 5:
Nursing Considerations for Nursing Process: Implementation of the Administration of Medications by Different Routes
page 3

Tablets/Capsules
1. Unless a tablet is scored, it should never be broken to adjust dosage. Breaking can cause incorrect dosage, gastrointestinal (GI) irritation, or destruction of the drug in a incompatible pH...

An observation of medication administration was conducted with Employee Identifer # (EI) 5, the Licensed Practical Nurse (LPN) on 8/15/12 at 8:50 AM to Patient Identifer (PI) # 1. EI # 5 obtained a Namenda 10 milligrams (mg) from the medication system and placed the Namenda in the pill splitter to obtain the 5 mg dosage the patient was to receive. The surveyor observed no manufacturer's scoring line for the tablet. The surveyor asked EI # 5 if the tablet was scored and the response was, "No". The surveyor observed EI # 5 administer the 1/2 tablet of Namenda to PI # 2.


An observation of medication administration was conducted with EI # 5 on 8/15/12 at 9:10 AM to PI # 2. EI # 5 obtained a Toprol 50 mg from the medication system and placed the scored Toprol in the pill splitter to obtain the 12.5 mg the patient was to receive. EI # 5 split the tablet one time along the score line. EI # 5 then took the 1/2 tablet and split it into 1/4 tablet. The surveyor asked if the tablet had 2 scores and the response was, "no just one". The surveyor observed EI # 5 administer the 1/4 tablet of Toprol to PI # 2.

An interview was conducted with EI # 6, the Director of Nurses on 8/15/12 at 2:30 PM. The surveyor requested a policy on the splitting of medications and the response was, "There is not one here."

An interview was conducted on 8/16/12 at 8:45 AM with EI # 3, the Pharmacist. The surveyor asked if it was acceptable to split an unscored tablet or split a tablet in 1/4. The repose was, "They do it every where I have ever been".

Based on observations, review of policy and interview, it was determined the facility failed to ensure:

1. All supplies/medications available for patient use were not expired.

2. Multi dose medications were labeled when opened.

This had the potential to negatively affect all patients served at the facility.

Findings include:

Facility Policy
Subject:Use of Multiple Dose Vials (MDVs) revised 7/20/12

"Policy:

MDV may be used for for than one patient if not accessed in a direct patient care area.

The beyond-use date (BUD) for an opened or entered (i.e. needle-punctured) multiple dose container with antimicrobial preservatives shall be 28 days, unless otherwise specified by the manufacturer.

The healthcare provider shall write the date opened on the vial, and initial..."

A tour was conducted on 8/14/12 at 2:30 PM in the Outpatient Rehabilitation area. The surveyor observed the following multiple dose vials opened without a date or initials:

1 - Dexamethasone Sodium Phosphate 10 milligrams (mg)/milliliter (ml) 10 ml bottle

1- Dexamethasone Sodium Phosphate 4 milligrams (mg)/milliliter (ml) 1 ml bottle.

An interview was conducted with Employee Identifier (EI) # 7, Licensed Physical Therapy Assistant (LPTA), on 8/14/12 at 2:45 PM. The surveyor asked how long the 2 bottles had been open and the response was, "I am not sure."

An interview was conducted with EI # 8, the Physical Therapy (PT) Director on 8/15/12 at 11:00 AM. The surveyor discussed the 2 open vials found in the PT department and EI # 8 stated, "I did not think the policy included my department."

An observation of care provided in the Endoscopy area was conducted on 8/14/12 at 7:30 AM. The surveyor noted the following expired biologicals:

1 - Suture Removal Kit with an expiration date of 2011-04

1- 22 gauge Jelco 22 gauge with an expiration date of 2011-02

1 - 25 gauge Jelco with an expiration date of 2005-09

1 - Bottle of 0.9% Sodium Chloride 500 ml with an expiration date of 1-April-2012

1 - bottle of Iodoform Packing Strip with an expiration dated of 2012-01

1 - Scrub Care Chlorhexidine Gluconate Solution Surgical hand scrub with an expiration date of 2011-06.

A tour of the Medical - Surgical medication preparation area was conducted on 8/15/12 at 9:40 AM.

The surveyor observed 1 green top laboratory tubes which expired 2012-05 and 8 green top laboratory tube which expired 2012-03.

Based on the review of the Plan of Correction submitted after the survey dated 7/4/12, observations and interviews with facility staff, it was determined the facility failed to ensure:

1. Kitchen area was clean from excessive grease and dust.

2. Expired supplies were not available for patient use.

Findings include:


Review of the Plan of Correction for the survey dated 7/4/12 revealed the following:

The dietary manager will implement a cleaning schedule and inservice all dietary staff accordingly on or before 7/30/12... Ongoing compliance will be monitored by administrator or designee weekly.

An initial tour of the Kitchen/food preparation area was conducted on 8/14/12 at 10:30 AM. During this tour, the surveyor observed excessive grease and dust buildup on the top shelf of the stove. The surveyor observed thick black burnt-on substance behind the warming table and on top of the baking ovens.

The surveyor requested a copy of the Dietary Cleaning Schedule on 8/14/12 at 11:15 AM. EI # 2, the Dietary Supervisor submitted the following schedules titled:

Dietary Air Conditioner and Light Cleaning Schedule
Bake Area Cleaning Schedule
Trayworkers Cleaning Schedule
Salad Area Cleaning Schedule
Cooks Daily Cleaning Schedule

An interview was conducted on 8/14/12 at 11:45 AM with EI # 2. The surveyor asked EI # 2 to explain the Cleaning Schedule process. EI # 2 stated (EI #2) had posted a laminated copy of each schedule in the designated areas. When the employee had completed each task they were to initial the task on the laminated copy. At the end of the week (EI#2) would check each schedule and wipe the laminated copy clean. The surveyor asked where the copies of the completed schedules were and the response was, "I do not keep a copy."


Review of the inservice titled Dietary Cleaning Schedule dated 7/30/12, revealed no documentation of attendance by Employee Identifiers (EI) # 9 and 10, Dietary Aides # 1 and 2.

An interview was conducted with EI # 4, the Chief Financial Officer on 8/15/12 at 9:15 AM. The surveyor asked why the 2 above dietary employees did not attend the inservice titled Dietary Cleaning Schedule. At 9:30 AM on 8/15/12 EI # 4 submitted to the surveyor a sign in sheet with EI # 9 and 10 signatures.

On 8/15/12 at 9:45 AM the surveyor requested the dietary staffing schedule for the past 2 weeks and documentation the Dietary Manager had ongoing monitoring of the cleaning on a weekly basis. EI # 4 submitted a time report for 7/29/12 to 8/11/12 and 8/12/12 to 8/25/12 and a review of the weekly cleaning schedule stating it is done on Fridays.

Review of the time report for 7/29/12 to 8/11/12 revealed no documentation the following dietary staff worked 7/30/12, the day of the Dietary Cleaning Schedule inservice:

EI # 9, Dietary Aide # 1
EI # 11, the Cook
EI # 12, Dietary Aide # 3
EI # 13, Dietary Aide # 4
EI # 14, Dietary Aide # 5
EI # 15, Dietary Aide # 6

An interview was conducted with EI # 11 on 8/16/12 at 8:30 AM. The surveyor asked what inservices had EI # 11 attended since 7/4/12. EI # 11 stated Hand Washing and Food Preparation. The surveyor asked if EI # 11 had attended the inservice for the Dietary Cleaning Schedule and the response was, "no." The surveyor showed EI # 11 the time report for 7/29/12 to 7/31/12 and stated that the first day on the schedule was 7/31/12. EI # 11 stated she/he had been off and the 7/31/12 was a paid day off.

A tour of the kitchen was conducted on 8/16/12 at 8:45 AM to observe the Dietary Cleaning Schedules posted in each area. The surveyor observed the following:

Bake Area Cleaning Schedule - Blank for Saturday, Sunday, Monday and Tuesday.

Trayworkers Cleaning Schedule- Blank Saturday, Sunday, Monday, Tuesday, Wednesday and Thursday.

Salad Area Cleaning Schedule- Blank Saturday, Sunday, Monday, Tuesday, Wednesday and Thursday.

Cooks Daily Cleaning Schedule- Blank Saturday, Sunday, Monday, Tuesday, and Wednesday.

An observation of care provided in the Endoscopy area was conducted on 8/14/12 at 7:30 AM. The surveyor noted the following expired biologicals:

1 - Suture Removal Kit with an expiration date of 2011-04

1- 22 gauge Jelco 22 gauge with an expiration date of 2011-02

1 - 25 gauge Jelco with an expiration date of 2005-09

1 - Bottle of 0.9% Sodium Chloride 500 ml with an expiration date of 1-April-2012

1 - bottle of Iodoform Packing Strip with an expiration dated of 2012-01

1 - Scrub Care Chlorhexidine Gluconate Solution Surgical hand scrub with an expiration date of 2011-06.

A tour of the Medical - Surgical medication preparation area was conducted on 8/15/12 at 9:40 AM.

The surveyor observed 1 green top laboratory tube which expired 2012-05 and 8 green top laboratory tube which expired 2012-03.

Based on observations, review of the facility's policies, the Plan of Correction submitted after the survey dated 7/4/12, Medical Staff Meeting Minutes and CDC (Center for Disease Control) Guidelines and interview, it was determined the facility failed to ensure the staff followed their own policies for hand hygiene and wound care. This had the potential to negatively affect all patients served by this facility.

Findings include:

Review of the Plan of Correction for the survey dated 7/4/12 revealed the following:

Appropriate hand hygiene education was provided for the medical staff during their routine meeting on 07/05/12.

************

Guideline for Hand Hygiene in Health-Care Settings 2002

Part II Recommendations

1. Indications for handwashing and hand antisepsis

I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient...

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Facility Policy: Hand Hygiene - CDC Guidelines

Purpose: To provide guidelines for effective hand hygiene, in order to prevent the transmission of bacteria, germs and infection.

Policy:

All personnel will use the hand-hygiene techniques, as set forth in the following procedure...

Before each patient encounter.

After contact with medical equipment/supplies in patient areas.

************

Facility Policy: Dressing Change - Wet-To-Dry

Procedure:

...Clean scissors with alcohol prior to placing on clean field...

Remove equipment and supplies used in procedure. Discard disposable items and clean equipment (scissors, etc) to be reused with alcohol...

Observation of care was conducted on 8/15/12 at 7:30 AM between Procedure Rooms # 4 and 5. The surveyor observed multiple surgical staff enter and exit procedure room # 5 without hand hygiene.

On 8/15/12 at 8:00 AM the surveyor observed Employee Identifier (EI) # 17, Physician, exit procedure room # 5 (after an EGD (Esophagogastroduodenoscopy)), perform hand hygiene, complete paper work, leave the area to talk with family, return to the area, complete more paper work, enter procedure room # 4 and begin a Colonoscope with possible Hemorrhoid Banding without hand hygiene.

Review of the Medical Staff Meeting Minutes dated 7/5/12 revealed EI # 17 was absent.

Observation of wound care was conducted on 8/15/12 at 10:30 AM with EI # 18, Licensed Practical Nurse (LPN) and Patient Identifier (PI) # 5. The surveyor observed EI # 18 remove scissors from EI # 18's pocket and place them on PI # 5 bed. After providing wound care, EI # 8 picked the scissors up off the bed and replaced them in her/his pocket. EI # 18 picked up the excess gauze and tape and returned to the nurses station. EI # 18 placed the unused gauze in the trash reciprocal and the unused tape in the general supply area.

An interview was conducted with EI # 6, the Director of Nurse on 8/15/12 at 2:30 PM. The surveyor asked if the nurse used the scissors appropriately and should the tape have been returned to the general supply area and the response was, "No".
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20228

Based on review of the Humidity and Temperature Logs, policies and interviews, it was determined the facility failed to follow their own policy and assure the operating rooms were monitored for safe parameters of humidity for 1 of 2 operating rooms. This had the potential to negatively affect all patients who had surgical procedures performed at the facility.

Findings include:

Facility Policy: Operating Room Suite Physical Environment

Purpose: To identify general standards relating to the operating rooms.

Policy: The operating rooms will meet specifications for maintaining a safe environment for the surgical patient...

The temperature range should be 68 degrees to 75 degrees Farenheit and the humidity will be maintained at 30 to 60 percent.

Review of the Temperature and Humidity Log for Operating Room # 1 revealed the humidity should read between 70 - 20%. The following humidity readings had been documented:

7/26/12 = 64%
7/27/12 = 61%
7/30/12 = 61%
7/31/12 = 64%
8/1/12 = 61%
8/8/12 = 65%
8/9/12 = 65%
8/10/12 = 65%

An interview was conducted on 8/14/12 at 2:00 PM with Employee Identifier (EI) # 16, the Director of Surgery. The surveyor asked why the facility policy for humidity read 60% as the upper limit and the log read 70% as the upper limit. EI # 16 stated the policy was going to change to 70%. The surveyor asked if 70% was an acceptable standard for the humidity reading in an operating room. EI # 16 responded " no the log should have read 60%". EI # 16 stated 70% was documented in error.

Tonya Blankenship, RN