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Based on interview and record review, the facility failed to ensure that high risk medications were administered in a safe manner and as ordered by the physician in 1 of 5 sampled patients (Patient #9) who were reviewed for anti-coagulant therapy.

Patient #9 received the wrong dose of the anti-coagulant drug, Heparin, on 02/28/2020 after a nurse pulled the wrong paper downtime protocol form.

The facility's Administrative nursing staff failed to ensure staff nurses were re-trained on the usage of Heparin (anti-coagulant) downtime protocol forms after the medication error occurred.

This deficient practice had the likelihood to cause harm to all patients on anti-coagulant therapy.

Refer to A tag 405 for additional information.

Based on interview and record review, the facility failed to ensure high risk medications were administered in a safe manner and as ordered by the physician in 1 of 5 sampled patients (Patient #9) who were reviewed for anti-coagulant therapy.

Patient #9 received the wrong dose of the anti-coagulant drug, Heparin, on 02/28/2020 after a nurse pulled the wrong paper downtime protocol form. The facility failed to ensure staff nurses were re-trained on the usage of Heparin (anti-coagulant) downtime protocol forms after the medication error occurred.

This deficient practice had the likelihood to cause harm to all patients on anti-coagulant therapy.


Findings:


Review of the Emergency department (ED) record dated 02/25/2020 at 11:56 a.m., revealed Patient #9 was an 87-year-old female who presented with chief complaints of chest discomfort and fast heart rate.

According to the ED record Patient #9 was found to have the following:

"CLINICAL IMPRESSION

New onset atrial fibrillation with uncontrolled rate.

Acute mild systolic, congestive heart failure.

Small left effusion associated with acute congestive left ventricular failure.

Acute renal failure ..."



According to the ED notes Patient #9 was admitted to the medical floor on 02/25/2020 at 2:15 pm.

Review of a physician order dated 02/28/2020 at 2:30 p.m., revealed some of the following anti-coagulant medication orders:

". Heparin 20,000 Unit/500 ml DRIP.."

". Initial IV rate: 15 units /kg (kilogram)/hr.."

"Draw Heparin Xa level after Heparin initiated (lab used to measure the amount of Heparin in the blood stream). Repeat q 6 hours until 2 consecutive levels are therapeutic..."



Review of lab results dated 02/28/2020 at 4:57 p.m., revealed an unfractionated Heparin level (Heparin Xa) which was low at 0.16 (reference ranges being 0.3-0.7).

Review of a medication administration record and nurse's notes written by Staff #6 (registered nurse/RN) dated 02/28/2020 revealed Patient #9 was started on a Heparin drip infusing at 18 units per hours at 5:57 p.m.

Review of nurses notes dated 02/28/2020 at 8:50 p.m., written by Staff #20 (RN) revealed documentation that the Heparin was still infusing at 18 units.

There was no physician's order on the chart for the Heparin to be started at 18 units per hour.


Review of nurses notes written by Staff #20 dated 02/28/2020 at 10:00 p.m., revealed a call was received from Staff #22 (physician) about the "TRANSFER/HEPARIN DRIP." Staff #22 (physician) VERBALIZED THAT PT IS ON LOW DOSE HEPARIN DRIP. NOTED PROTOCOL SHEET ON HIGH DOSE (BUT LOW DOSE ON EMAR), ADJUSTED DRIP RATE C CO STAFF AT 15 UNITS/KG/HR, DR (#22) WAS INFORMED OF THIS AND WAS ADVISED TO WOF BLEEDING."

Review of lab results dated 02/28/2020 at 12:04 midnight, revealed an high unfractionated Heparin level of 0.77 (reference ranges being 0.3-0.7).

Review of nurses notes dated 02/29/2020 at 0030 revealed Patient #9 was discharged to another hospital via ambulance service.

Review of nurses notes dated 02/29/2020 at 0050 revealed the critical lab of 0.77 was relayed to the ambulance service and Patient #9's heparin drip was reduced to 13 units/kilogram/hour.



During an interview 10/14/2020 after 9:00 a.m., Staff #17 (Director of Quality) confirmed the medication error found in the chart. Staff #17 (Director of Quality) confirmed a medication error was made and provided a medication error report. Staff #17 reported that Staff #6 (RN) started the Heparin at the wrong rate and Staff #23 (RN) was the witness to initiation of the medication. Staff #20 (RN) was the one who recognized the error and reported it. Staff #17 (Director of Quality) confirmed the nurses could still use the paper protocol forms and there had not been any changes in their system.


During an interview on 10/14/2020 after 10:00 a.m., Staff #2 (Chief nursing officer) confirmed the medication error occurred. Staff #2 said the paper protocol forms that Staff #6 (RN) used was for downtime usage only. They still had the protocol forms in usage and there had been no system change with other nurses since the error occurred.


During an interview on 10/14/2020 after 10:52 a.m., Staff #6 (RN) confirmed she started the Heparin and accidently pulled the wrong form. Instead of pulling a low dose she pulled a high dose form. Staff #6 (RN) confirmed she had not looked at the physician's order on the computer prior to starting the medication. Staff #6 (RN) stated that Staff #13 (clinical coordinator) had written her up for the medication error. Staff #6 (RN) confirmed that they were still able to use the paper protocol downtime forms.

During an interview on 10/14/2020 after 11:14 a.m., Staff #13 (clinical coordinator) confirmed that she had investigated the medication error and written up Staff #6 (RN). Staff #13 (clinical coordinator) said she had not written up Staff #23 (RN) on the incident because Staff #6 (RN) gave the medication. Staff #13 (clinical coordinator) provided documentation of a skills fair on 02/18-20/2020 and stated that they talked about Heparin drips in that training. When asked if she had talked to the nurses after the medication error occurred on 02/28/2020 and about usage of the downtime forms she said "no".


Review of a facility's policy named "Medication Administration" reviewed 02/2020 revealed the following:


".. Medications will be administered using the "FIVE RIGHTS":

1. Right Patient

2. Right Medication

3. Right Dose

4. Right Time

5. Right Route.."



"..High risk medications require a second nurse witness; these medications have a pencil symbol below the medication on the eMAR.

1. These medications require two (2) licensed nurses to check prior to administration. If given by infusion, prior to initiation of infusion, two nurses will verify the proper IV pump setting in addition to the dose of the following:

a. Insulin

b. Heparin

c. IV KCL

d. Neuraxial analgesia

e. Narcotic PCA and EPCA infusions

f. Theophylline

g. NACL solutions > 0.9% .."

Based on observation, document review and interview the facility failed to:

1. properly prevent the transmission of COVID-19 and follow Centers for Disease Control and Prevention (CDC) Guidelines and Recommendations regarding screening of all staff and Health Care Providers upon entering the facility.

2. ensure education and training was provided to staff for the reprocessing of N95 masks (a particulate-filtering facepiece that protects the respiratory tract of the individual wearing them) to mitigate the spread of COVID-19 during a pandemic.


Cross Refer to Tag A0749

Based on observation, document review and interview, the facility failed to:

1. properly prevent the transmission of COVID-19 and follow Centers for Disease Control and Prevention (CDC) Guidelines and Recommendations regarding screening of all staff and Health Care Providers upon entering the facility. Temperature checks were available, but no COVID-19 screening questions were asked at 2 (end of the emergency hallway and entry at dock) of 2 designated employee entrances.

3. ensure education and training was provided to staff for the reprocessing of N95 masks to mitigate the spread of COVID-19 during a pandemic in 2 (Staff #18 and #19) of 2 employees.



This deficient practice had the likelihood to cause serious harm injury, and possibly subsequently death. Failure to adhere to the CDC's recommendations and guidelines placed all patients and staff at a higher risk for contracting and transmitting COVID-19.


Findings include:


Findings for #1:

Upon entry into the facility on 10-13-2020 at 9:50 AM, Surveyors were stopped at the entrance. Questions related to COVID-19 exposure, symptoms of COVID-19, and a temperature was taken. A green armband was placed on the surveyors and surveyors proceeded to Staff #1's office. Staff #1 directed the surveyors to a small administrative conference room.

An interview was conducted on 10-13-2020 after 10:00 AM with Staff #2 and #3. Staff #2 and Staff #3 were asked to explain the current facility protocols for the prevention and containment of COVID-19. Staff #3 confirmed all CDC Guidelines were followed to ensure patient and staff safety.


Staff #3 was asked if the facility had any positive COVID-19 patients. Staff #3 replied, "Yes we do, we have 10 patients that are positive at this time. The non-critical patients are in a private, negative pressure room, in the CVU (Cardiovascular Unit). Critical patients are in the ICU (Intensive Care Unit) in negative pressure rooms." Staff #2 stated, "We have made the CVU an isolation unit for COVID-19 patients. There are some patients on the unit that are not COVID-19 positive, but we do try and cohort patients that are positive in one area of the unit but, it's not always possible."

An interview was conducted on 10-13-2020 at 11:15 with Staff #7. Staff #7 was asked if visitors were allowed in the facility and what processes they were taking to ensure all visitors and patients were screened for COVID-19. Staff #7 stated, "Yes, we allow visitors at this time. They all enter through the Emergency Room doors or the main entrance of the hospital. All visitors are required to stop and have their temperatures taken and they are asked about symptoms and exposure to COVID-19. If their temperature is below 99.9 degrees Fahrenheit, and screening questions are negative they are given an arm band indicating they have been screened." Staff #7 was asked how the employees are screened before they enter the building. Staff #7 stated, "Staff are instructed to come through one of the two entry points. One is by the dock and the other is at the end of the ER (Emergency Room) hallway. There is a thermal scan thermometer at both locations. The employee places their head in for a temperature reading. If the temperature is greater than 99.9 degrees Fahrenheit, an automatic page is sent to the house supervisor (Clinical Nurse Leader). The employee is instructed by the house supervisor to return home and contact their unit director. Staff #8 will then contact the employee by telephone with further instructions. Staff #7 was asked if there was any screening questions related to COVID-19 symptoms or exposures asked to any employee or Health Care Provider before they entered the facility. Staff #7 replied, "No." Staff #7 was then asked if she could supply documentation that all staff completed a temperature screen before entering the facility. Staff #7 stated, "No I cannot ensure you that every staff member or Health Care Provider checks their temperature before they enter the facility." Staff #7 was asked if there was an alarm that would notify someone when they temperature scan was bypassed. Staff #7 replied, "No." Staff #7 confirmed the facility followed all CDC Guidelines and Recommendations related to COVID-19.

Staff #3, #6, #7, and #8 confirmed no screening for COVID-19 symptoms, exposure, or travel are asked at 2 of 2 designated employee entrances. Only a temperature was taken.


A review of the CDC's current recommendations revealed:

" ...Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic

Infection Control Guidance
Updated July 15, 2020

Background
This interim guidance has been updated based on currently available information about COVID-19 and the current situation in the United States. As healthcare facilities begin to relax restrictions on healthcare services provided to patients (e.g., restarting elective procedures), in accordance with guidance from local and state officials, there are precautions that should remain in place as a part of the ongoing response to the COVID-19 pandemic. Most recommendations in this updated guidance are not new (except as noted in the summary of changes above); they have been reorganized into the following sections:

Recommended infection prevention and control (IPC) practices for routine healthcare delivery during the pandemic

Recommended IPC practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection

This guidance is applicable to all U.S. healthcare settings


Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19

Although screening for symptoms will not identify asymptomatic or pre-symptomatic individuals with SARS-CoV-2 infection, symptom screening remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented.

Take steps to ensure that everyone adheres to source control measures and hand hygiene practices while in a healthcare facility

Post visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) to provide instructions (in appropriate languages) about wearing a cloth face covering or facemask for source control and how and when to perform hand hygiene.

Provide supplies for respiratory hygiene and cough etiquette, including alcohol-based hand sanitizer (ABHS) with 60-95% alcohol, tissues, and no-touch receptacles for disposal, at healthcare facility entrances, waiting rooms, and patient check-ins.

Limit and monitor points of entry to the facility.

Consider establishing screening stations outside the facility to screen individuals before they enter.

Screen everyone (patients, HCP, visitors) entering the healthcare facility for symptoms consistent with COVID-19 or exposure to others with SARS-CoV-2 infection and ensure they are practicing source control.

Actively take their temperature and document absence of symptoms consistent with COVID-19. Fever is either measured temperature ?100.0°F or subjective fever.

Ask them if they have been advised to self-quarantine because of exposure to someone with SARS-CoV-2 infection.



People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms may have COVID-19:
Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea

This list does not include all possible symptoms. CDC will continue to update this list as we learn more about COVID-19 ..."



A review of the facility policy titled,

" ...COVID-19 Outbreak and Work Restrictions", effective 3/2020 and revised 8/12/2020 was as follows:

Policy:
...
N. Employee Screening:
1. Employees will be screened with a temperature check as they enter the building at the beginning of their shift. Any employee with a temperature greater than 99.9 degrees Fahrenheit will be sent home ..."

Staff #7 and Staff #8 confirmed they cannot ensure all employees or Health Care Providers were screened with a temperature check before entering the facility.


A review of the facility policy titled "Influx of Infectious Patients/Coronavirus Disease Emergency Management and Surge Plan" effective 3/20 with a revision date of 7/24/2020 was as follows:

" ...III. Procedure:

A. Mitigation
The following mitigation activities will be completed to enable prompt recognition and response to an influx of infectious patient:

...
4. **** has temporarily implemented respiratory illness screening at designated entry points and visitor precautions to mitigate the spread of illness (see Appendix B) ...


Appendix B COVID Screening Instructions, Visitor Precautions
...
Employees and medical staff do NOT require screening but will have their temperature taken at the employee entrances.

All patients and visitors are to be screened without exception ..."

Staff #7 and Staff #8 confirmed the above criteria did not meet the CDC Guidelines and Recommendations for COVID-19 screening.


Staff #3 confirmed the above findings.




Findings for #2

A review of the employee files for Staff #18 and Staff #19 revealed the following:


Staff #18 had a signed job description for the position of "REPROCESSOR" dated 8/20/2020.

Staff #19 had a signed job description for the position of "REPROCESSOR" dated 9/01/2020.


A review of the signed job descriptions for Staff #18 and Staff #19 was as follows:

" ...POSITION SUMMARY
Re-processors will be responsible for the UV disinfection of N95 respirators of all clinical staff to ensure that PPE is always available. Disinfection will be facilitated by using UV emitters to process N95 respirators. The processors will collect used respirators from throughout the hospital, re-process to disinfect the respirators or prepare new to replace broken respirators, and then prepare respirators to be used again. Clean respirators will then be distributed back to the unit they were retrieved from ..."

An interview was conducted on 10/13/2020 at 2:20 PM with Staff #9. Staff #9 was asked if there was any training or competencies completed for Staff #18 and #19 for the reprocessing of the N95 masks under the UV lighting. Staff #9 stated, "No, I do not have any documentation of Staff #18 or Staff #19's training for the reprocessing of the N95 masks." Staff #9 was asked if Staff #18 and #19 were performing the disinfection of the N95 masks currently. Staff #9 stated, "Yes they are. In the beginning, we used furloughed employees, mostly surgery employees, to complete this task. Now that surgery is working again I hired two part-time employees to be responsible for all the N95 reprocessing. I know I should have documented training, but I do not at this time."


Staff #3 and Staff #9 confirmed the findings.