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Based on observation, staff interviews, and review of facility policy and procedure it was determined the facility staff failed to ensure that medication cabinets in non-secure areas were locked at all times, and that open multi-dose vials were labeled with an open or expiration date, and that an open multi-dose vial included a label which included the patient's name.

Findings include:

On 4/11/17 at 8:00 AM, the surveyor, was accompanied by Staff Members #1 and #3 to Unit 6A to observe a medication pass. While waiting for Staff Member #7, the unit's Patient Care Director to arrive, the surveyor observed that a cabinet door equipped with a key pad lock located beside the automated medication dispensing system was open. The surveyor observed multiple medications including pills, inhalers, nasal sprays, IV (intravenous) medications in the open cabinet. The cabinet also contained Accu-check glucometer supplies.

Staff Member # 1, the CNO (Chief Nursing Officer) stated "We just recently had all these locks replaced". Staff Member #7 arrived, and the surveyor asked if the cabinet was routinely kept locked, which staff had access to the cabinet, and what medications and supplies were kept in the cabinet. Staff Member #7 stated, "Yes, it is always locked, someone just didn't lock it back". Staff Member #7 attempted to close and lock the cabinet door; however, it would not lock. He/she then said "Only nurses have access to this cabinet; pharmacy returns, pharmacy drop offs, supplies for medication administration, and glucometer supplies are kept in this cabinet".

The facility's policy and procedure titled "Medication system and administration" stated in part the following: "...System for Med Administration: Medication cabinets in non-secure areas are to be locked at all times...", and
"..."Storage: Any drug received from the pharmacy should be placed in an approved secured storage area as soon as possible, not to exceed 30 minutes from time of receipt.".

The surveyor conducted an review of the medication refrigerator on Unit 6A, and observed an unlabeled box containing an open multi-dose vial of Miacalcin 400 I.U. (international units)/2 ml (two milliliter) vial with a manufacturer's expiration date of 5/2018. At 8:45 AM on 4/11/17 the surveyor asked Staff Member #7 the shelf life of the open multidose vial, how staff would know when to discard the medication without an open date or expiration date written on the vial, and how staff was able to determine who the medication belonged to with no name label on the medication.

Staff Member #7 pointed to the manufacturer's expiration date printed on the vial and stated "this is the expiration date". Staff Member #7 stated "Usually this is in a plastic bag with a patient name on it. This medication belongs to a patient who isn't here anymore, I'll return it to the pharmacy". Staff Member #7 then went to call the pharmacy to discuss the medication. While Staff Member #7 was on the phone with the pharmacy, Staff Member #1 stated "Our policy is that after a multidose vial is opened, it is discarded 28 days later. Some drugs are required to be discarded at 30 days, some are 28, so we just chose to discard all open multidose vials after 28 days. We write the expiration date, 28 days after being opened, on the vial, (Staff Member #7's name) should know that".

The facility's policy and procedure titled "Medication system and administration" stated in part the following: "...Injectables: Multidose vials that are not dated by pharmacy are to be destroyed at the end of the case or at 12 midnight of the day opened...".

Staff Members # 1, 3, and 7 were aware of the concerns at the time of discovery, and the observations were again discussed with members of administration on 4/13/17 between 12:30 PM and 1:00 PM.

Based on staff interviews, a review of medical records for 3 patients who received blood transfusions, review of the facility policy and procedure for administration of blood products, and staff interviews, it was determine facility staff failed to ensure that 3 of 3 patients were monitored per the facility policy and procedure. Patients #17, #7 and #6.

Findings include:

The facility policy and procedure titled "Blood and blood product transfusion" included the following information related to documentation: "Vital signs including temperature should be documented at the following intervals:
15 minutes prior to giving blood or blood product for baseline; every 15 minutes x 2 (times two) (15 and 30 minutes after starting infusion); then 30 minutes later (1 (one) hour after starting infusion); every hour until completion of the infusion; 15 minutes after completion of infusion".

Staff Member #9 assisted the surveyor in navigating the records of patient's receiving blood transfusions (#6, #7, #17).

1. Nursing documentation in Patient #17's record indicated the patient received 2 units of PRBC's (packed red blood cells) on 4/8/17. The first unit was infused between 10:49 AM and 1:25 PM, and VS (vital signs) were monitored per policy.

Patient #17 received a second unit of PRBC's on 4/8/17 between 9:20 PM and 11:50 PM. Post transfusion VS were were not documented until 1:50 AM, 2 hours after the completion of the infusion.

2. Nursing documentation in Patient #7's record was that the patient received 1 unit of PRBC's on 4/10/17 between 1:40 AM and 4:40 AM. There were no VS documented 15 minutes prior to the transfusion to obtain a baseline; VS were obtained per policy between 1:56 AM and 4:10 AM; however, there were no VS documented again until 7:30 AM, more than 2 hours after completion of the infusion".

3. Nursing documentation in Patient #6's record was that he/she received 1 unit of PRBC's on 4/1/17 between 8:10 PM and 10:30 PM. Baseline VS were not obtained prior to beginning the blood transfusion. Temperatures were not documented with VS at 10:00 PM. The post transfusion VS were obtained 30 minutes after completion of the infusion, rather than 15 minutes, and did not include documentation of the temperature.

On 4/8/16, Patient #6 received 1 unit of PRBC's between 10:45 AM and 1:00 PM. Post transfusion VS were not obtained until 2:00 PM, 1 hour after completion of the infusion.

On 4/9/16, Patient #6 received a platelet transfusion between 9:15 AM and 1:45 AM; baseline VS were not documented prior to starting the infusion.

Concerns were discussed with Staff Member #9 at the time of the findings, and again on 4/13/17 with members of administration between 12:30 PM and 1:00 PM.