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MOUNT SINAI MEDICAL CENTER OF FLORIDA, INC
ADMINISTRATION OF DRUGS
Tag No.: A0405
Based on observation, interview and policy / procedure review, the facility failed to ensure that proper infection control practices were followed during the preparation of injectable medication when the vial's rubber septum was not disinfected with alcohol prior to the needle entering the vial in accordance with PolicyStat ID 8084152 Safe Injection Practices for 1 of 6 Sampled Patients (SP). SP#5
Findings include:
Observed medication preparation on 06/22/2023 at 10:30 AM for SP#5. Registered Nurse (RN2) verified the medication order. RN2 obtained the vial of IV medication (methocarbamol) and performed the following steps:
(1) Hand hygiene performed and donned non-sterile gloves.
(2) Removed the top from the medication vial and proceeded to prepare the syringe.
(3) Injected needle into the vial rubber septum.
Interview conducted with the Nurse Manager and Nursing Director on 06/22/2023 at 10:40 AM on the unit, after the medication pass to discuss the concern observed related to disinfecting the vial septum.
Review of the facility policy and procedure, PolicyStat ID 8084152 Safe Injection Practices, 4.3.035 last approved on 11/2020 included but was not limited to:
IV. Policy: The potential for infection and transmission of microorganisms exists during the administration of any type of medication. Drug administration by injection offers many opportunities for contamination. "Safe Injection Practices" are part of Standard Precautions.
V. Procedure: The following recommendations should be followed when using needles, cannulas that replace needles and intravenous delivery systems:
9. Use a standardized protocol to disinfect catheter hubs and injection ports before accessing. Prior to any IV access, vigorously wipe the hub or port using an alcohol soaked pad and a friction rub for 5 seconds.
The facility policy on safe injection practices were not followed when the rubber septum on the medication vial was not disinfected by RN2 with alcohol prior to the needle being inserted into the septum to withdraw medication from the vial.