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Based on record review and staff interview the facility did not ensure that controlled substances that were discontinued were wasted properly and that the discard of the medication was accounted for in the facility record in accordance with facility policy for 1 of 10 medical records reviewed on survey.

Findings:

-Review of patient #1's medical record showed a physician order dated 10/3/18 at 0758 to discontinue the patient's patient controlled analgesia (PCA) pump and discontinue the patient's intravenous fluids.

-Review of Clinical Notes dated 10/4/2018 at 0821 indicated that the patient's PCA pump was found attached to the IV pole in the patient's room with IV tubing still connected to the pump but detached from the patient. The IV tubing delivering the narcotic (Dilaudid) was found laying on the floor and there was a puddle of unknown origin nearby. The 10/4/2018 Clinical Note also recorded that the nursing staff who cared for the patient on 10/3/2018 did not sign the pertinent documents in the narcotics folder, or patient's chart.

-The 10/4/2018 Clinical Note also documented that the IV of Lactated Ringers solution that was to be discontinued along with the PCA pump was still infusing into the patient, more than twenty four hours after it was supposed to be discontinued.

-Review of the facilty's policy on Controlled Substances (effective date 2/22/93; last review 5/31/17) indicates the following in Section 8: Documentation of Disposal/Destruction/Wasting. The Manager is to be notified, wipe the spill and discard in regular trash. Contact Pharmacy and provide details including drug and approximate amount lost and contact information.

-The Director of Hospital Regulatory Affairs stated on interview on 3/8/19 at 1157 that she had spoken with the Nurse Manager of the Unit who stated that an incident report was not initiated and that the spill was cleaned and discarded.

-Failure to properly discard unused Controlled Substances can result in diversion of those substances to other patients, staff or visitors.

Based on medical record review and staff interviews, the facility failed to ensure that all staff provide care in accordance with acceptable standards of infection prevention for 1 of 10 patients (index patient #1) reviewed on survey. Findings:

-Review of Clinical Notes (nursing notes) dated 11/8/2018 indicated that a registered nurse (RN) observed a small spot of soiling on the Ace wrap covering the patient's left leg dressing. The Clinical Notes documented that the RN discussed this observation with the on call physician. MD notified of the Wound Ostomy Continence Nurse (WOC) note. The RN charted that the MD response was to wait and change the dressing tomorrow with the WOC can reassess the need for a wound vac. At the time, the patient had Clostridium difficile diarrhea and was on transmission based precautions. Patient #1's soiled dressing should have been changed since the patient was susceptible to infections.

-The Infectious Disease MD and the Infection Preventionist were interviewed by survey staff on 4/10/2019 at 1:09 PM and indicated that they had reviewed the medical record and agreed the patient's dressing should have been changed.

-Review of the facility's Infection Control Manual (revision date 5/18) conducted on 3/15/2019 revealed the facility has incorporated Centers for Disease Control and Prevention (CDC) guidelines as hospital standards.

-Review of a Clinical Note dated 11/30/2018 at 1207 indicated the patient's wife reported to the nurse that her husband's dressing to his LBKA sited had been off for 3 to 4 hours. Nursing staff documented she paged the orthopedic resident.

-Review of a Clinical Note dated 11/30/2018 at 1553 indicated the nurse paged an orthopedic resident three times to come to the unit and redress the patient's wound.

-Review of a Clinical Note dated 11/30/2018 at 1555 indicated the resident responded to the page and will come to the floor to dress the patient's wound.

-Review of a Clinical Note dated 11/30/2018 at 1854 indicated that "Ortho" rewrapped patient #1's left lower extremity. This was more than five hours after initial notification to orthopedics to replace the patient's dressing. Nursing staff failed to cover the patient's wound with a sterile dressing while waiting for the orthopedic service
to respond.

The patient was at risk for infection due to peripheral vascular disease, diabetes, and non intact skin due to a surgical wound.


20205