HospitalInspections.org

Based on observation, interview, and policy review, the provider failed to ensure:
*The hospital had an infection control (IC) plan developed and implemented for fiscal year 2016.
*The IC program integrated one of one on-campus practice location into the hospital IC program.
*The hospital had a preventative maintenance process to identify and maintain operating room (OR) bed mattress pads, stretcher mattress pads, and positioning devices in good serviceable condition.
*Expired medical supplies were not available for patient use in one of one OR suite.
*Staff performing an endoscopic procedures for one of one sampled patient (25):
-Transported the esophagogastroduodenoscopy (EGD) scope in a manner to preserve the high-level disinfection (HDL) status prior to use.
-Wore appropriate personal protective equipment (PPE) during the procedure.
-Completed hand hygiene at the end of the procedure.
*Laryngeal airways and endothracheal blades were maintained in a clean and sanitary manner prior to use in one of one operating room (OR).
*Suction tubing and suction tips were maintained in a sanitary manner in all pre/post-operative care rooms.
*Supplies used for coffee were not stored adjacent to the handwashing sink in the post-anesthesia care area.
*Spray bottles of chemical cleaners were not used in one of one OR suite.
*Single-use items of betadine were not reused in one of one OR suite.
*The eyewash station was not located at the decontamination sink in one of two decontamination rooms (utility room next to the procedure room).
Findings include:

1. Review and interview on 9/14/16 at 3:36 p.m. of IC information with infection control preventionist (ICP) G revealed:
*There was no IC information for the on-campus Lewis & Clark Medical Plaza with functions related to clinical laboratory and physical therapy.
*ICP G revealed she was not aware that on-campus clinic should have been incorporated into the hospital's IC program.
*Review of the IC information revealed an Infection Control Plan for Fiscal Year 2015. ICP G stated a plan had not been developed for Fiscal Year 2016.

2. Observation on 9/14/16 at 7:43 a.m. revealed:
*Surgical technician (ST) L with her bare hands carried the EGC scope from the utility room into the procedure room with her bare hands. She then proceeded to test the suction apparatus on that scope still not wearing gloves.
*During the procedure ST L and operating physician M did not wear protective eyewear with side shields or a face mask. Both wore their personal eyeglasses.
*The medical student conducted a rectal examination of the patient and assisted with holding the patient in position with no protective gown over his scrub attire, eye protection, or a face mask. The medical student removed his contaminated gloves, did not perform hand hygiene, and put on a clean pair of gloves.
*Circulating ST C assisted with holding the patient in position for a short interval without a protective gown, eye protection, or a mask.
*Registered nurse (RN) M during the procedure administered medications intermittently into the patient's intravenous (IV) site. RN N had to reach for the patient's arm which was tucked close to her body. RN N was not wearing protective eyewear, a cover gown, or a mask.
*At the end of the case the physician removed his gown and gloves, the medical student removed his gloves, and both exited the procedure room without performing hand hygiene.

Interview with ST L immediately after the procedure revealed:
*She should have worn eye protection during the procedure.
*The procedure was not a sterile procedure, only clean, and was not aware handling the EGD scope with bare hands potentially contaminated the scope.

Interview on 9/14/16 at 3:36 p.m. with ICP G revealed:
*EGD procedures were a clean procedure.
*She was not aware HLD items should have maintained that level of disinfection until the equipment was used on the patient.
*Staff should have worn PPE at the appropriate times during the procedure to prevent contamination of their scrub uniform and cross-contamination.
*Eye protection should have been worn to protect the staff from potential contamination.

Review of the provider's August 2013 Hand Hygiene policy revealed handwashing should have been performed before putting on gloves, after removing gloves or other personal protective equipment, when visibly dirty or contaminated with blood or other body fluids, and before and after patient contact.

Review of the provider's undated and untitled policy relating to infection control provided by the director of nursing revealed:
*Standard precautions barriers included:
-Gloves which are worn whenever there was a potential for exposure to "blood/blood products/body fluids with visible blood."
-Masks which "Should be worn during procedures that are likely to generate droplets/splashing of blood/body fluids."
-Gowns/Aprons which "Should be worn when there is potential for soiling clothing with blood/body fluids."
-Eyewear should have been "Worn during procedures that are likely to generate droplets of blood/body fluids."

The policy for endoscopic procedures had not been provided to the survey team by the end of the survey.

Review of Association of periOperative Registered Nurses [AORN] 2016 Edition Guidelines for Perioperative Practice revealed:
*Page 683 - "Personnel working in the endoscopy suite must wear PPE whenever splashes, spray, spatter, or droplets of blood, body fluids, or other potentially infectious material may be generated and eye, nose, or mouth contamination can be reasonably anticipated."
*Page 684 - "Hand hygiene should be performed after removal of PPE, because hands may become contaminated with PPE removal, gloves may have microscopic tears."
*Page 765 - "High-level disinfected items should be transported to the point of use using a technique that does not result in recontamination of the instrument (eg. aseptic technique). Performance of hand hygiene, donning gloves to handle HLD items, and transferring immediately to point of use following processing are examples of practices that minimize recontamination."

3. Observation on 9/13/16 at 9:29 a.m. and on 9/14/16 at 7:30 a.m. revealed the following items had uncleanable surfaces:
*OR:
-One patient stretcher in the hallway had cracked corner seams exposing the pad underneath.
-OR 3 the OR bed black plastic protective covering had numerous small holes and the corner seams were cracked.
-OR 2:
----The OR bed had a dime size hole in the black plastic protective covering that exposed the foam padding underneath.
----A blue foam positioning device plastic covering had a small hole exposing the foam padding underneath.
----A silicone gel pad had a dime size hole in the plastic covering and was sticky to the touch.
----A black positioning device foam padding was covered with tape.
*Post-anesthesia care unit room 2, the stretcher mattress pad corners were torn at the seam.

Interview on 9/13/16 at 1:50 p.m. with RN N revealed there was no formal method to report repairs. They just picked up the phone and reported items to material management when found. There were no work orders completed for needed repairs.

Interview on 9/14/16 at 3:36 p.m. with ICP G revealed there was no formal program for ensuring repairs were completed when found. There was no environmental rounds done in the hospital to identify necessary repairs for equipment or the environment. The maintenance personnel completed repairs when they found things that needed repair.

4. Observation on 9/13/16 revealed:
*At 10:47 a.m. on the anesthesia cart in OR 2 were several opened packages of suction tubing. Patient 26's surgical procedure was being completed at that time.
*At 1:19 p.m. in OR 3 an emergency airway equipment container. Inside the container were several loose, unprotected laryngeal mask airways (LMA), stylets, and laryngeal blades. Inside the anesthesia cart were several laryngeal blades unprotected.
*At 1:50 p.m. in OR 2 loose unprotected laryngeal blades in the anesthesia cart.

Interview on 9/14/16 at 10:14 a.m. with certified registered nurse anesthetist revealed:
*There was another certified registered nurse anesthetist working Monday and had probably opened the suction tubing.
*The LMA and blades did not have to be sterile, only clean.
*He agreed there was a potential for the LMAs, stylets, and blades to become contaminated as stored.
*The items were not packaged because they were needed in an emergency.

5. Observation and interview on 9/13/16 at 1:50 p.m. and on 9/14/16 at 2:14 p.m. with RN N revealed in the:
*OR:
-Povidone iodine scrub brushes one box had expired in February 2016.
-Bleach germicidal cleaner one bottle had expired on 4/8/16.
-Exempt Human Specimen Kits four boxes had expired on 3/31/14 and two boxes expired on 6/3/14.
-EZ scrub expired in October 2014.
*Procedure room:
-Alcare foam antiseptic handrub had expired in August 2011.
-Triesence vial had expired in March 2016.
-Simbrinza solution had expired in July 2016.
*RN N confirmed the above listed items had expired and stated outdates were checked on a monthly basis.

Interview on 9/14/16 at 3:39 p.m. with the ICP revealed expired supplies should not be available for patient use and should have been discarded.

6. Observation on 9/13/16 at 1:33 p.m. in OR 2 and at 2:02 p.m. in OR 3 revealed several small spray bottles and pour bottles of betadine in use. The bottles were labeled by the manufacturer for single use only. Interview at the time of the above observation with RN N confirmed the bottles were currently being used, and was not aware they were single-use only items.

Interview on 9/14/16 at 3:39 with the ICP confirmed single-use items should have been discarded and not stored for later use.

7. Observation on 9/13/16 at 2:30 p.m. and on 9/14/16 at 9:25 a.m. in the pre/post-anesthesia care unit rooms 1, 2, 3, and 4 revealed:
*Sterile suction tubings and suction tips packages had been opened.
*The tubings and tips were connected, attached to the wall suction, and stored in the opened package at the wall suction.

Interview on 9/14/16 at 9:25 a.m. with RN O revealed:
*The suction tube and tips were stored that way until use and then discarded.
*That was the normal facility practice in the pre/post-anesthesia area.
*Multiple patients used the rooms throughout the day and there was a potential for contamination.

8. Observation and interview with ST C on 9/14/16 at 8:35 a.m. in the utility room adjacent to the procedure room revealed:
*The eyewash station at one time had been located on the handwashing sink.
*It had been moved recently to the decontamination sink.
*The signage was not posted, it was laying half-way face down on the counter.

Review of AORN, page 681, revealed "Eyewash stations are located in well lit areas with a highly visible sign, eyewash stations should not be installed in a location that require flushing of the eyes in the decontamination sink, splashing from the decontamination sink can potentially contaminate eyes."

Interview on 9/14/16 at 5:10 p.m. with the administrative staff revealed the eyewash station had recently been replaced due to Occupational Safety and Health Administration requirements. They were not aware of the practice contraindication of not placing it on the decontamination sink.

9. Observation on 9/13/16 at 8:15 a.m. and on 9/14/16 at 7:26 a.m. revealed coffee supplies (cups, spoons, and creamer) were stored on the counter immediately adjacent to the handwashing sink. Interview with the director of nursing on 9/14/16 in the morning confirmed the coffee service was too close to the handwashing sink. Those items were at risk for potential contamination.

10. Observation on 9/13/16 at 9:29 a.m. and on 9/14/16 at 7:30 a.m. revealed use of stainless steel cleaner and polisher, and bleach germicidal cleaner spray bottles.

Interview on 9/14/16 at 3:36 p.m. with the ICP revealed she was not aware of the spray bottle usage and should not be used in the OR.

Review of AORN, page 11, revealed "Spray and misting methods (eg. a spray bottle) should not be used to apply chemicals (cleaning) in the OR setting. Aerosolization can contaminate wounds, supplies, sterile field if contaminated, and cause respiratory symptoms in patient and staff."

Based on record review, interview, and policy review, the provider failed to ensure discharge planning reflected one of one sampled patient's (6) psychiatric needs at the time of discharge. Findings include:

1. Review of patient 6's Discharge Planning form revealed:
*He had been admitted on 4/4/16 and was discharged on 4/8/16.
*He was disabled, able to care for himself, and would be returning home with his girlfriend.
*He had a diagnosis of bipolar disorder and was currently receiving treatment for emotional/behavioral problems.
*His current admission diagnosis was chronic abdominal pain.
*The initial discharge planning form was completed on 4/4/16. A summary of care/progress on that same form was completed on 4/8/16. The form indicated he was returning to the same level of care (home).
*On the 4/8/16 Postoperative Discharge Instructions under follow-up was documented "Pt [patient] requests not to be called with post-op this weekend."
*No documentation of a post-op phone call at a later date was recorded on the form.

Review of patient 6's medical record and interview with registered nurse (RN) K revealed:
*His physician's 4/8/16 Discharge Summary indicated:
-"The patient had threatened suicide during the hospitalization. When confronted with this, he admitted that it is just his way of expressing how much pain he has been having and he does not have the guts to through with any type of suicide. He said that if he did, he would have done it a couple of months ago. He did not feel like he is a threat to himself at this time. He does not feel like he is a threat to anyone else at this time either."
-He had a history of severe abdominal pain and pancreatic cancer.
-He had contacted the physician's office because of severe abdominal pain and needed to be admitted for pain control.
-His pain had been controlled with Fentanyl patches.
*His nursing notes from 4/4/16 through 4/8/16 indicated:
-On 4/4/16 at 8:00 p.m. he became upset when his medications Seroquel and Celebrex were brought into the room. The patient became "immediately agitated "and stated "I take 2 of each of those in the morning! Get them out of here!" The nurse documented the medications were given as ordered.
*On 4/4/16 at 8:30 p.m. he was observed by the nurse removing two Tylenol from a bottle of extra strength Tylenol he had brought from home. The nurse had documented the patient denied bringing any medications from home upon admission. The patient put the medication back into the bottle and gave the bottle to the nurse.
*On 4/4/16 at 9:00 p.m. the physician was called for an order for anti-nausea medication. The physician was notified of the patient's behavior. The physician advised the staff to call the police department if they felt unsafe with the patient.
*There were no documentation of the patient's threat to commit suicide.

Interview and review of patient 6's medical record on 9/14/16 at 2:04 p.m. with RN K revealed:
*She recalled patient 6 and his 4/4/16 admission.
*He had been placed on one-to-one observation with a watcher because of a suicide threat.
*There was no documentation in his medical record of that one-to-one observation.
*There was no physician's order for one-to-one observation.
*There were no physician's progress notes regarding the patient's suicide threat.
*His care plan did not reflect interventions for suicide precautions.
*The director of nursing had been notified of his suicide threat and for guidance, however she was out of town.
*The administrator had contacted the physician regarding the patient's behavior and suicide threat.

Interview on 9/15/16 at 5:00 p.m. with the administrator and director of nursing revealed:
*Patient 6 should not have been admitted or remained a patient in the hospital after his suicide threat. The appropriate treatment at that time should have been a transfer to an acute care facility that could meet his psychiatric needs.
*Physician M had been consulted regarding the patient's behavior and getting a psychiatric evaluation of the patient had been discussed, but not ordered by the physician.
*Lewis & Clark hospital did not have the capability to treat patients exhibiting signs and symptoms of a psychiatric condition.

Interview on 9/15/16 at 1:00 p.m. with physician M regarding patient 6 revealed:
*He had became more docile with pain medication adjustments. He had been on a medication that caused anxiety.
*There was a thought about getting a psychiatric evaluation, but not a lot of discussion.
*The next morning his disposition was better.
*He calmed down when physician M was in his room.
*There was nothing in discharge planning about follow-up with his psychiatric care giver after discharge.
*The patient had insisted on coming to Lewis & Clark for treatment. He had reminded the patient he had to mind his manners.
*Ultimately he did not feel Lewis & Clark was the best place for him; however he could not recall if it was with the current admission or another admit.
*Lewis & Clark did not have the specialists the patient needed like hospice doctors, social worker, or an oncologist.
*He had burned a lot of bridges with doctors in town, and had informed the patient he would take him on as a patient if he acted better.

Review of the provider's undated Discharge Planning policy revealed the discharge planning screening criteria included but was not limited to reviewing the patient diagnosis, identified psychiatric problems, and terminal conditions.

Review of the provider's Patient Scope of Care policy revealed:
*"The Lewis & Clark Specialty Hospital is designed to meet the needs of surgical patients requiring pre-operative and post-operative medical care."
*"Patients will only be denied admission to the facility if their needs cannot be adequately and safely met by the facility. In such cases those patients will be stabilized as much as possible and transferred to an acute care center."
*"Admissions must not require intensive/critical care services. A patient with a medical history or presenting illness that may likely require critical care services at any time during the hospital stay is not a candidate for admission to the facility."
*"If a patient's medical condition changes after admission and it is determined that their health care needs can no longer be met by the services, staff, and equipment available at the hospital, an immediate transfer according to the physician's orders will be required."

Based on employee file review, job description review, policy review, and interview, the provider failed to ensure:
*Competencies had been completed for three of three sampled registered nurses (RN) (A, D, and G) for one of one crash cart.
*Competencies for high level disinfection (HLD) or sterilization had been performed for one of one sampled surgical technician (B).
*Nurses had current advanced cardiovascular life support (ACLS) certification required by their job description for two of three sampled RNs (A and D).
*Nurses had current pediatric advanced life support (PALS) certification required by their job description for one of three sampled RNs (G).

1. Review of RN A's employee files revealed:
*There was no documented crash cart training.
*Her ACLS certification had expired in January 2016.

Interview on 9/14/16 at 10:40 a.m. with RN A regarding her ACLS certification revealed:
*It had expired in January 2016.
*She had planned to renew it, but had not had time.

2. Review of surgical technician B's employee file revealed no documented HLD or sterilization training.

Review of the provider's November 2011 Surgical Technician/Certified Technologist/Certified First Assist job description revealed the surgical technician must demonstrate competency.

3. Review of RN D's employee file revealed:
*There was no documented crash cart training.
*There was no documented ACLS certification.

4. Review of RN G's employee file revealed:
*There was no documented crash cart training.
*Her PALS certification had expired in August 2016.

5. Review of the provider's November 2011 Registered Nurse job description revealed:
*The RN should have demonstrated the ability to perform technical skills and management of equipment within the area of assignment.
*Each assigned area required competencies.
*The competencies would have been done annually.
*ACLS and PALS certification would be required and completed if not already certified.



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6. Interview on 9/14/16 at 10:45 a.m. with the director of nursing regarding employee competencies revealed she had:
*Been employed at the facility for two and one-half years.
*Not completed any competencies on any of the employees.
*Planned on doing employee competencies, but had not started them.

7. Review of the provider's 1/14/10 Emergency Services policy revealed "Each RN is trained in CPR, ACLS, and PALS."

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29354

Based on record review, interview, and policy review, the provider failed to document an individualized nursing care plan for 6 of 20 sampled patients (1, 2, 6, 10, 11, and 13). Findings include:

1. Review of patient 1's medical record revealed:
*She had been admitted on 9/12/16 for bi-lateral knee replacement surgery.
*There were no documented goals or interventions in the acute care portion of the medical record.

2. Review of patient 2's medical record revealed:
*An admission date of 9/13/16.
*A diagnosis of left knee total joint replacement on 9/13/16.
*The kardex had not included interventions or goals.

Interview on 9/14/16 at 8:15 a.m with patient 2 regarding her care revealed they had not "really" informed her of any specific interventions or goals related to her post surgical care.

Interview on 9/14/16 at 2:30 p.m. with registered nurse (RN) H regarding resident 1 and 2's kardex revealed:
*They used the kardex for patient care.
*There was not a care plan for patients 1 and 2's care.
*The kardex had no individualized patient interventions or goals listed.

3. Review of patient 6's medical record revealed:
*He had been admitted on 4/4/16.
*His diagnosis was persistent midline abdominal pain and bipolar disorder.
*On 4/4/16 at 8:00 p.m. the patient became upset when his medications Seroquel and Celebrex were brought into the room. The patient became "immediately agitated "and stated "I take 2 of each of those in the morning! Get them out of here!" The nurse documented the medications were given as ordered.
*On 4/4/16 at 8:30 p.m. the patient was observed by the nurse removing two Tylenol tablets from a bottle of extra strength Tylenol he had brought from home. The nurse had documented at the time of admission the patient had denied bringing any medications from home. The patient put the medication back into the bottle and gave the bottle to the nurse.
*On 4/4/16 at 9:00 p.m. the physician was called for an order for anti-nausea medication. The physician was notified of the patient's behavior. The physician advised the staff to call the police department if they felt unsafe with the patient.
*His discharge summary dated 4/8/16 revealed the patient had threatened suicide during the hospital stay.
*The kardex/medical record had no individualized patient interventions or goals for behaviors, his diagnosis of bipolar disorder, or suicide.

Interview on 9/14/16 at 2:04 p.m. with RN K confirmed patient 6's medical record did not have a care plan. RN K revealed when the facility had switched back to paper charting there was no process put into place for nursing care plans.

4. Review of patient 10's medical record revealed:
*He had been admitted on 5/24/16 for a left total knee replacement surgery.
*There were no documented goals or interventions in the acute care portion of the medical record.

5. Review of patient 11's medical record revealed:
*She had been admitted on 5/24/16 with a diagnosis of non-infective gastritis.
*There were no documented goals or interventions in the acute care portion of the medical record.

6. Review of patient 13's medical record revealed:
*She had been admitted on 7/11/16 for right hip surgery.
*There were no documented goals or interventions in the acute care portion of the medical record.

7. Interview on 9/14/16 at 1:50 p.m. with the director of nursing revealed:
*Since the provider switched from electronic to paper medical records care plans were documented in each patient's chart.
*Some nurses documented goals and interventions in their nursing notes.

Review of the provider's 1/14/10 Post Operative Nursing Care policy revealed "Purpose: To assess patients and provide appropriate post operative nursing care."

Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 8th Ed., St. Louis, Mo., 2013, p. 244, revealed "A nursing care plan includes nursing diagnoses, goals and/or expected outcomes, specific nursing interventions and a section for evaluation findings so any nurse is able to quickly identify a patient's clinical needs and situation."

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29354

Based on record review, interview, and policy review, the provider failed to ensure:
*Two of twenty sampled patients (4 and 6) had a history and physical timed and dated by the physician when signed.
*Thirteen of twenty sampled patients (1, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, 16, and 18) had an operative report timed and dated by the physician when signed.
*Seven of twenty sampled patients (1, 6, 7, 10, 11, 12, and 13) had a discharge summary timed and dated by the physician when signed.
Findings include:

1. Review of patients 4 and 6's medical record revealed the history and physical had been signed, but not timed and dated by the physician.

2. Review of patients 1, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, 16, and 18's medical record revealed the operative report had been signed, but not timed and dated by the physician.

3. Review of patients 1, 6, 7, 10, 11, 12, and 13's medical record revealed the discharge summary had been signed, but not timed and dated by the physician.

4. Interview on 9/14/16 at 3:25 p.m. with the director of nursing confirmed all entries in the medical records should have a date and time.

5. Review of the provider's August 2010 Medical Records Documentation policy revealed "All documentation in the medical records must include date, time and signature."

Based on record review and interview, the provider failed to ensure staff obtained a blood consent form prior to administering fresh frozen plasma to one of one sampled patient (6) that had received a transfusion. Findings include:

1. Review of patient 6's medical record and interview with registered nurse K on 9/14/16 at 2:04 p.m. revealed:
*The laboratory report dated 4/5/16 indicated critical lab values in PT and INR (indicators for blood clotting time). The PT was 42.6, normal range is 11.3-14.0; and his INR was 3.5, normal range is 0.7-1.5.
*He received four units of fresh frozen plasma on 4/5/16.
*There was no consent form signed by the patient for transfusion of fresh frozen plasma.
*The patient should have signed a consent form prior to the administration of the plasma.

Review of the provider's August 2010 Informed Consent policy revealed:
*The "Physician performing a medical or surgical procedure/treatment is responsible for obtaining the patient's informed consent prior to the procedure/treatment. The individual performing the procedure/treatment may be a physician, registered nurse or other healthcare provider approved and qualified to perform the procedure."
*An "Informed consent is required for surgical and other invasive procedures/treatments with significant risks, and transfusion of blood and/or blood products."
*The staff should have completed an "Approved hospital consent form(s) on all cases involving a procedure/treatment for which documented consent is required, and place it in the medical record prior to the treatment or procedure."

Based on observation, interview, and policy review, the provider failed to ensure:
*Expired medications were not available for patient use in one of one operating room (OR) and one of one procedure room.
*Staff put a date of opening and their initials on multi-dose vials when opened in two of two patient care areas (OR and procedures room).
*Single use medication vials were not reused in one of one OR suite.
Findings include:

1. Observation and interview on 9/13/16 at 1:50 p.m. with registered nurse (RN) N revealed:
*In OR 2 anesthesia cart:
-One opened multi-dose vial of labetalol with the date "7/16" handwritten on the label. RN N was not sure if that was the vial opening date or the discard date.
*In OR 3 anesthesia cart:
-One vial of two percent xylocaine with a needle puncture mark in the rubber septum. The manufacturer's label stated single-use only.
-Several multi-dose vials:
--Succinylcholine with no date of opening or staff initials.
--Glycopyrrolate with no date of opening or staff initials.
--Dexamethasone with no date of opening or staff initials.
--Labetalol with the handwritten date of "4/12."
*In the procedure room:
-One opened multi-dose vial of Celestone with no date of opening or staff initials.
-Triesence vial expired March 2016.
-Simbrinza solution expired July 2016.

Interview on 9/13/16 at 4:17 p.m. with the director of nursing revealed:
*Anesthesia providers were responsible for checking for outdated medications on anesthesia carts.
*Multi-dose vials should have been dated when opened and they were good for 28 days unless otherwise stated by the manufacturer.
*Single-dose medication vials should not have been saved for use later.

Review of the provider's undated Single Use Devices and Drugs policy revealed:
*"Multiple dose drugs are good for 28 days after opening of the vial. This date should be recorded on first opening with initials."
*"Single dose drugs if opened should be discarded 1 hour after opening."
*"All out of date drugs, either opened or unopened will be delivered to the pharmacy."

Based on observation, interview, and manufacturer's package insert review, the provider failed to ensure:
*The overflow intravenous (IV) supplies were stored in a clean environment for one of one nurse report room.
*Staff documented the control solutions correct high and low lot numbers for one of one glucometer.
Findings include:

1. Observation on 9/13/16 at 9:30 a.m. in the nurse report room where the overflow IV supplies were stored revealed:
*Five clear plastic totes that contained 0.9 percent sodium chloride irrigation USP.
-Those totes did not have lids on them.
*A dead black beetle was found in with the IV solution in one of the totes.

Interview on 9/13/16 at 9:45 a.m. with patient care technician I revealed:
*The supplies in that area were not on a routine cleaning schedule.
*Supplies stored in other areas of the facility were on a routine cleaning schedule.

Interview on 9/15/16 at 10:15 a.m. with the human resource manager who had confirmed with the materials manager by phone revealed:
*Those supplies were not on a routine cleaning schedule.
*There was no policy or procedures for the cleaning of the area where those supplies were stored.



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2. Interview and testing on 9/13/16 at 3:12 p.m. of the glucometer with registered nurse (RN) J and lab technician (LT) B revealed the lot number for the high and low control test solutions had the same number. Review of the labels on the high and low test solution revealed the first six numbers of the lot numbers were the same, however the last number was different for each vial of solution. Interview at the time of testing with RN J and LT B confirmed the staff only documented the first six numbers of the lot number because those numbers were the same on both vials. RN J and LT B agreed when the last digit of the lot numbers were considered the numbers would have been different for the high and low solution vials.

Review of the September 2016 quality control record for documented glucose results revealed the lot numbers listed for the high and low results were the same.

Review of the manufacturer's package insert instructions for use revealed "Verify that the lot number on the vial matches the lot number on the table of assay values." The table of assay values for the high and low solutions were listed as different numbers.