HospitalInspections.org

Based on record review, observation, and interview, the hospital failed to:

a. provide pharmaceutical/ biological services according to national standards of practice (see Tags C-0276, and C-0297),
b. mitigate the risks that contribute to healthcare-associated infections (see Tag C-0278), and
c. provide adequate nursing care to meet the needs of the patients (see Tags C-0294, C-0296, and C-0297).

These failed practices had the risk of un-authorized persons gaining access to and improper accounting of medications; exposing patients to infectious diseases and providing substandard care to an average of 832 inpatients admitted the hospital per year.

37609


Based on observation, record review, and interview the hospital failed to:
A. ensure the pharmacy remained locked at all times,
B. limit access to the pharmacy department,
C. report and correct controlled substance discrepancies in the omnicell, an automated medication dispensing machine, in a timely manner,
D. ensure omnicell was stocked with adequate amount of medications for patient care on a daily basis,
E. ensure all multiple dose medications were labeled with the time and date it was opened,
F. ensure patient's home medications were identified by the pharmacist prior to use,
G. be accountable for all controlled substances located within the hospital,
H. administer total parenteral nutrition (TPN) according to manufacturer's instruction for use in the 5 patients who received TPN in 2017, and
I. clearly define the vital sign monitoring intervals for patients receiving blood transfusion (approximately 74 units of blood administered annually).

Findings:

A. Pharmacy Door

Hospital policy titled, "Medication Security" stated pharmacies shall be locked at all times.

On 05/09/17 at 10:44 am, surveyors observed the pharmacy door unlocked and opened. The pharmacy is located in between 2 exit doors that lead to the outside.

On 05/10/17 at 11:26 am, the pharmacist (Staff I) stated the pharmacy's door being unlocked and open is the hospital's normal practice. Staff I stated controlled substances remain in a locked cabinet and therefore the unlocked and open door is not an issue.

B. Pharmacy Access

Hospital policy titled, "Medication Security" stated authorized staff allowed access to the pharmacy include the pharmacists, medication room supervisors, and charge nurses or nurse representative.

Another hospital policy titled, "Drug Inventory Control" stated access to the pharmacy shall be limited to pharmacists and Pharmacy Services staff.

A report of badge access to pharmacy, between the dates of 11/09/16 to 05/09/17, showed 5 staff members (excluding the 2 pharmacy staff) were granted access multiple times during and after pharmacy hours.

Granted access:
~Staff DD had 21 granted badge accesses from January 2017 thru May 2017.
~Staff EE had 23 granted badge accesses from January 2017 thru May 2017.
~Staff O had 10 granted badge accesses from January 2017 thru May 2017.
~Staff F had 236 granted badge accesses from January 2017 thru May 2017.
~Staff B had 39 granted badge accesses from January 2017 thru May 2017.

The above access doesn't include the key access that is granted to all the RN staff. The hospital has 35 listed RN staff members employed.

C. Controlled Substance Discrepancies

A hospital policy titled, "Automated Dispensing Machines-Controlled Substances" stated if a discrepancy is created it should be communicated with the pharmacy. Controlled substance discrepancies must be resolved at the time of discovery or by the end of the shift.

Another hospital policy titled, "Diversion Prevention of High Risk & Controlled Medications" stated conflicting information which included discrepancies will be resolved within a maximum of 72 hours.

On 05/08/17 at 12:32 pm, during a tour of the Medical Surgical Unit Medication Room, surveyors observed 4 discrepancies in the Omnicell for the following controlled substances that were not resolved immediately, by end of shift, or within 72 hours.

~Ativan 1 mg tablets
~Ativan 2 mg/1 ml vials
~Ambien 5 mg tablets (twice)
~Norco 10/325 mg tablets

The "Pharmacy Discrepancy Report" for "May 1-8, 2017" showed the above discrepancies took place between 05/02/17 thru 05/05/17; and not resolved until the morning of 05/09/17 (4-7 days later).

The "Pharmacy Discrepancy Report" for the month of April 2017 showed a total of 17 of 20 controlled substance discrepancies:
~13 of 20 controlled substance discrepancies were not resolved at all.
~4 of 20 controlled substance discrepancies were not resolved upon discovery, by the end of the shift, or within 72 hours.

The "Pharmacy Discrepancy Report" for the month of March 2017 showed a total of 10 of 15 controlled substance discrepancies:
~4 of 10 controlled substance discrepancies were not resolved at all.
~6 of 10 controlled substance discrepancies were not resolved upon discovery, by the end of the shift, or within 72 hours.

The "Pharmacy Discrepancy Report" for the month of February 2017 showed a total of 6 of 10 controlled substance discrepancies were not resolved upon discovery, by the end of the shift, or within 72 hours.

The "Pharmacy Discrepancy Report" for the month of January 2017 showed a total of 3 of 17 controlled substance discrepancies were not resolved upon discovery, by the end of the shift, or within 72 hours.

On 05/08/17 at 12:32 pm, Staff G, Drug Room Supervisor, stated discrepancies are resolved once a week.

D. Stocked Medications on Patient Care Units

Hospital policy titled, "Automated Dispensing Machines-Stock Medication" documented Pharmacy Services will be responsible for stocking all medications in the automated dispensing machine and inventory levels will be checked daily.

Documents titled "PHA After Hours Log" from April 16, 2017 thru May 9, 2017 showed multiple non-Pharmacy Services staff entrees into the pharmacy to restock the omnicell during pharmacy hours and after hours.

Non-Pharmacy Services Staff Log Entrees:
~76 entrees were logged to restock the Medical Surgical Unit
~35 entrees were logged to restock the Emergency Department
~3 entrees were logged to restock the Surgical Area

On 05/10/17 at 10:47 am, staff G stated all omnicells are stocked daily approximately 2 pm, prior to the pharmacy closing and pharmacy service is on-call after hours.

E. Multiple dose Medications

Surveyor requested a policy pertaining to multiple dose medication, recieved a hospital policy titled "Use of Multiple Dose Vials (MDVs)". The policy stated for a multiple dose medication an expiration will occur 28 days after the medication is opened and the healthcare providers shall write the expiration date on the medication when it has been punctured.

During a tour of the Emergency Department medication room, surveyor observed a multiple dose bottle of "Acid Gone Antacid" opened without an expiration date located in an unlocked cabinet.

Drug Room Supervisor and Director of Nursing (DON) confirmed the medication was opened without an expiration date.

F. Patient's Home Medications

A policy titled, "Patient's Own Medication Storage and Destruction" stated patient medications brought from home that can't be sent home with family should be logged into the patient's medication log on the appropriate form with patient's name, name and strength of drug and prescription number and number of tablets; and sent to the Pharmacy Services for storage.

On 05/09/17 at 10:40 am, surveyors observed in the Medical Surgical Unit Medication Room, a patient's home medication in a bag located in a cabinet. The content in the patient's bag were 2 daily pill organizer with medications inside and 3 bottles of medications labeled Hydrocodone 7.5 mg with medication inside.

The DON stated there was no form, with patient's home medications logged, to account for the medications.

On 05/09/17 at 11:59 am, Staff G stated patients' home medications are currently not verified or stored by pharmacy services.

G. Accountability for Controlled Substances

Hospital policy titled, "Controlled Substance Administration" stated 2 licensed nurses will complete a narcotic and barbiturate count at the change of each shift in both the Emergency Department and on the Medical Surgical unit; and a narcotic journal record count will be completed twice a day at the beginning of each shift.

A narcotic journal record count sheet was reviewed from the Emergency Department which contained the following:

~Twenty-two dates (04/03/17, 04/10/17, 04/11/17, 04/12/17, 04/17/17, 04/18/17, 04/19/17, 04/20/17, 04/21/17, 04/24/17, 04/25/17, 04/26/17, 04/27/17, 04/28/17, 04/29/17, 04/30/17, 05/01/17, 05/02/17, 05/03/17, 05/04/17, 05/05/17, 05/06/17) out of thirty-seven dates showed no documentation a narcotic count was completed on either shift.

~Three (04/04/17, 04/09/17, and 04/16/17) of three dates showed no documentation a narcotic count was completed on the night shift.

On 05/09/17 at 10:45 am, Staff O stated a narcotic count is completed each shift and the narcotic journal record count sheet is signed by the two nurses completing the count.


H. Total Parenteral Nutrition (TPN)

On 05/08/17 at 11:14 am, the CNO stated the hospital increased services to include the administration of total parenteral nutrition (TPN). [TPN is a method of getting nutrition through a vein.]. The hospital began to administer TPN services on February 3, 2017. From 02/03/17 to 05/12/17, 5 patients had received TPN infusions.

The Pharmacist showed surveyor the TPN product "Clinimix", and stated the product was used by the hospital. The Pharmacist provided the manufacturer's instruction for use for this product. The TPN instructions documented, "Verify that the 2 chambers are intact [one chamber contains dextrose and one chamber of amino acids]; discard if the seal has been activated inadvertently or if there are any leaks. Place the bag flat on a table with the label facing you. ...Grasp the bag firmly on each side on the hanger end. Using some pressure, roll the bag to open the seal between the chambers. If only half of the seal separated, flip the bag over and roll it again. The entire seal from top to bottom must be separated." The instruction documented the user should attach the administration set.

The CNO and Pharmacist demonstrated the method for properly activating TPN bag. The Pharmacist stated an in- line filter should be used for each infusion.

The hospital policy titled, "Parenteral Nutrition Protocol (no date)" documented the nurse should administer the TPN, but the policy failed to reference the critical manufacturer's instructions for activating the bag, and did not include the requirement of using specialized filtered tubing.

Hospital Incident Reports for 2017 showed 2 documented incidents that involved the failure to acticvate the TPN bags:
~ On 02/06/17, at approximately 11:00 am, unidentified RN observed TPN not fully activated and the amino acid portion only had infused, and there was no filter on the tubing. The bag and tubing changed. The incident report documented there was no harm to the patient.The action: CNO developed TPN policy, nursing competency, and order set for TPN. CNO ensure all staff caring for TPN have training, education, and competency.

~ On 04/19/17, Staff Y failed to manually separate the barrier on the TPN bag, and the patient only received the half of the bag containing amino acid. The error was found the next shift after the infusion had emptied.

Hospital documents titled, "Medication Management Competency Verification Form", Initial ED/Critical Care and RN Competency Verification Form" [Note: The hospital did not have a CCU RN. The CNO stated the CCU RN was a nurse with greater experience.], "RN Basic Competency Verification Form" and the "The LPN Basis Competency " did not contain skills checklist for the administration of TPN.

Twelve personnel files, and mutilple types of competency checklists for the nursing staff were reviewed. 11 of 12 staff (Staff H, Staff B, Staff M, Staff Q, Staff R, Staff S, Staff N, Staff K, Staff L, Staff AA, and Staff Z) failed to have a completed competency checklist of TPN administration in their personnel file.

A review of the "Heathlandweb Patient/ Chart showed Staff AA, an orientee, administered TPN to Patient # 29. No TPN competency was provided for Staff AA.

On 05/10/17 at 2:36 pm, surveyors observed staff L perform TPN administration. Before conneting the IV bag to the PICC line, staff L scrubbed the hub but then laid the catheter tips on the patient bed re-contaminating them. Staff L connected the IV line to the PICC line without cleaning the hub after contamination.

The CNO stated she and 4 other staff (Staff N, Staff Y, Staff Z, and Staff CC) went to Carney Hospital for TPN training. The surveyors requested the date of the training, the name of the trainer, and the training verification, and none was provided The hospital document titled "TPN Administration Procedure Checklist" for Staff K was reviewed. The checklist was dated 02/03/17; yet, the CNO signed as preceptor on 02/02/17. Staff K's TPN checklist did not indicate if the training was actual or simulated. The CNO stated she and the 4 staff would serve as trainers for the other staff.

I. Blood Administration

On 05/08/17, the CNO stated the hospital provided blood transfusions for both inpatients and outpatients. The CEO provided statistics for blood administration. In 2016, the lab released 74 units of blood, and 01/2017 through 5/2017, 32 units of blood.

The hospital's policy titled, "Blood/ Blood Components- Transfusion 11/19/15" was reviewed. The policy documented physician orders for transfusion should be verified. The policy directed staff to monitor vital signs (VS) blood pressure, temperature, pulse and respirations as follows:
~ every 5 minutes for the first 15 minutes, then (Note: 3 VS should be completed at 15 minutes)
~ every 15 minutes for the first 30 minutes, then
~ every hour until unit is infused, and
~ final set of vital signs following the completion of the transfusion, and
~ and 1 hr post transfusion.

The policy included a Blood Administration Form with instructions that the form should be completed with each unit transfusion. There were components of this form that did not match the directives within the body of the transfusion policy. The form had the following template for taking blood transfusion vital signs:
~ Start of transfusion (within 30 minutes of pre-VS) (Note: the policy did not require a starting set of VS), then
~ at 10 minutes (Note: the policy required at 5 minutes and 10 minutes VS) , then
~ at 15 minutes, then
~ at 30 minutes, then
~ at one hour, 2 hours, 3 hours, and 4 hours, then
~ VS at completion, and
~ 1 hour post transfusion

On 05/11/17, the CNO stated the Blood Administration Form had been created as part of a QAPI initiative to improve the documentation of vital signs for patients' receiving blood transfusions.

The hospital's incidents reports for January 2016 through March 2016, and January through May 2017 were reviewed. The reports contained only an unique report number, but no patient identifier, and included "Closing Remarks" written by the CNO.
The February/ March 2016 reports contained the following 5 incidents involving blood transfusions:
~01/26/16 Unspecified staff failed to take VS per policy (no specific details) Closing Remarks: Staff counseled and educated
~02/02/16 Unidentified staff administered 2 units of blood without an ordered. Order read to type and cross. "Closing remarks: Educated and counseled"
~02/23/16 Staff P documented the 5 and 10 minute VS were within normal limits and only documented VS at 5 minutes "Closing remarks: Disciplinary action taken..."
~03/09/16 Staff P did not follow policy for the infusion of 2 units (no details provided) "Closing remarks: Disciplinary action taken..."
~03/16/17 Unidentified staff did not take 1 hour post transfusion vital sign. "Closing remarks: Nurse counseled"

The January 2017 through May 2017 incident reports contained the following 8 incidents documented involving blood transfusions:
~02/05/17 Staff S (Agency) gave 2nd unit of blood and VS blank. Blood Steering Committee working on new procedures.
~02/06/17 Staff U left blanks on VS sheet. On 2nd unit, VS were not taken per policy, and completion times on various documents did not match. Closing Remarks: Blood Steering Committee working on new procedures. All staff educated and nurse associated with occurrence no longer employed. All nurses reeducated and for future occurrences, employees to receive disciplinary action.
~02/06/17 Unidentified staff failed to take VS on 2nd unit of blood, and completion times on various documentation did not match.
~02/08/17 Unidentified staff left multiple blanks of VS in documentation. No pre-vital signs and for 2nd unit. 2nd unit of blood, and completion times on various documents did not match. Closing remarks: Discussed event with RN. New VS flow sheet for blood administration created and approved by the Governing Body on 03/22/17.
~02/22/17 Staff U wrote verbal order for type and cross. When questioned by peer, Staff U wrote verbal order for transfusion. There were 3 blanks in VS (unspecified times). Charge Nurse had instructed another nurse, Staff L, to transfuse the blood. Staff L stated lack of competence in transfusions to which the Charge Nurse responded saying a watched video equated to competency. "Closing remarks: Blood Steering Committee working on new program to ensure quality blood administration."
~04/07/17 Staff T (Agency Staff) administered 2 units of blood and #2 VS blank (and Lasix was not given)
~04/18/17 Staff V & Staff W did not take VS per policy- blanks in VS and Post VS not taken.
~04/19/17 Staff L, Staff T (Agency) and Staff X were involved with the administration of a total of 6 units of blood to a patient. Unspecified blanks noted in the VS documentation. Last unit did not have an order.. Closing remarks: Spoke to Staff T (Agency), who said the last unit was transfused by staff.

The hospital had 3 competency checklists for the registered nursing staff, "Core Clinical Competency Validation- Position: Registered Nurse [the CNO stated this checklist was to be completed for Charge Nurses], "Initial ED/Critical Care and RN Competency Verification Form" [Note: The hospital did not have a CCU RN. The CNO stated the CCU RN was a nurse with greater experience.] and "RN Basic Competency Verification Form". The RN Basis Competency did not contain skills checklist for the administration of blood.

The personnel files for 10 employed RNs and 2 contracted RNs were reviewed for competency for blood administration. 3 of 10 employed staff files (Staff B, M, and Q) did not contain evidence of blood
administration competency. 2 of 2 agency staff files (Staff R and Staff S) did not contain evidence of blood administration competency.

Based on record review, observation and interview the hospital failed to mitigate infection risk or follow hospital guidelines for care of central venous catheters, infusaports and PICC lines.

This deficient practice had the potential to affect all patients with indwelling catheters and central lines.

Findings:

A document titled "Scrubbing the Hub", stated re-education was performed with all staff on 05/05/17 related to a 66.6% compliance with safely accessing indwelling catheters by cleaning the hubs with alcohol or chlorhexidine prior to flushing or medication administration.

Staff record review showed two of two contract registered nurses had no documented training or competencies on PICC line or central venous catheter care.

On 4/26/17 a patient complaint was filed on behalf of patient #14. The patient stated her nurse did not wear gloves or clean the hub of her IV catheter with alcohol prior to administering an antibiotic.

Physicians progress note dated 04/05/17, on patient #5, stated low grade fever secondary to PICC line.

The hospital's central line associated blood stream infection report stated there had been one recent case of PICC line associated infection. QAPI minutes dated 04/17/17 stated efforts had to be made to ensure nurses are being dilignet about scrubbing the hub for a full 10-15 seconds.

Nursing notes reviewed on patient #5 between the dates of 03/22/17-03/26/17 documented seven PICC line dressing changes while characterizing it as clean, dry and intact.

On 05/11/17 at 2:30 pm, the Chief Nursing Officer stated, according to hospital policy, the PICC line dressing should only be changed once every seven days unless soiled or detached and it should not have been changed if documented as clean, dry and intact; as excessive exposure increases risk for infection.

On 05/10/17 at 2:36 pm, surveyors observed staff L perform TPN administration. Before conneting the IV bag to the PICC line, staff L scrubbed the hub but then laid the catheter tips on the patient bed re-contaminating them. Staff L connected the IV line to the PICC line without cleaning the hub after contamination.

37609


Based on observation, record review, and interview the hospital failed to:

a. report and correct controlled substance discrepancies in the omnicell, an automated medication dispensing machine, in a timely manner.
b. ensure all multiple dose medications are labeled with the time and date it was opened.
c. ensure patient's home medications are identified by the pharmacist prior to use.
d. administer total parenteral nutrition (TPN) according to manufacturer's instruction for use in 2 of 5 patients receiving TPN,
e. follow hospital blood administration policy, as evident by lack of physician orders in 3 of 12 incidents involving blood products, and lack of monitoring of vital signs for 12 of 12 incidents involving patients receiving blood transfusions.
f. ensure oxygen was administered by trained staff and according to physician orders.

These deficient practice had the potential to affect every patient admitted to the hospital, who received each specifically defined service .

Findings:

A. Controlled Substance Discrepancies
See Tag 0276 Item C

B. Multiple dose Medications
See Tag 0276 Item E

C. Patient's Home Medications
See Tag 0276 Item F

D. Total Parenteral Nutrition (TPN)
See Tag 0276 Item H

E. Blood Administration
See Tag 0276 Item I

F. Oxygen Administration

Review of ten staff records showed 3 of ten (Staff B, M and Q) did not have nursing competencies or any documented training for the administration of supplemental oxygen.

2 of 2 agency nurse records failed to contain competencies or documented training on procedure for administering oxygen therapies.

QA/PI minutes dated 02/08/17 stated staff education was necessary following an incident where an unnamed staff administered oxygen to a patient without a physician's order.

In March 2017, a medical event was reported when an order for supplemental oxygen was delayed to a patient that was short of breath. The patient had been connected to the medical air instead of the oxygen.

On 07/25/16 a physician's order was written for patient #28 to receive 2 liters continuous oxygen via nasal cannula. On 07/27/16 staff V switched the patient to 2.5 liters oxygen via mask without a physician's order or without notifying the physician of a change in the patient's condition.

Staff V received a corrective action for violation of company policy and practicing out of a nurse's scope of practice.

An incident report was filed on 01/06/17 after respiratory therapy found that an unnamed swing bed patient had been receiving supplemental oxygen without a physician's order.

Based on record review and interview the hospital failed to develop policies regarding maintenance of records and safeguards against loss, destruction, or unauthorized use.

On 05/08/17 at 11:30 am, the surveyors requested the policies governing the removal of the clinical record or personal health information from the hospital premises.

Although multiple clincal record policies were provided to the surveyors, none of the policies addressed removal of the clinical record from the hospital premises.

On 05/10/17, the CEO stated he must discuss the lack of existence of such policy with the Director of Medical records.

Based on record review, interview, and observation, the hospital failed to develop an effective quality assurance program to improve long-standing patient care issues such as:

a. lack of vital sign monitoring for patients' receiving blood transfusions,
b. inadequate training and orientation program for employed and agency RN staff for blood adminisration, Total Parental Nutrition (TPN), and O2 application,

These failed practices had the potential to affect all patients receiving blood transfusion, oxygen, and medication administration.

Findings:

The hospital document titled, "Quality Assurance Perfromance Improvement (QAPI) (2017) defined the purpose of the program was to provide for a series of dynamically responsive and effectively integrated structures and sysytems that when woven into the day-to-day life of the organization, foster reliabilty and resilience in an ever changing patient care environment where the continuous introduction of new technology that advances what we can offer our patients makes our hospital setting a safety-critical environment.


a. Blood Administration

On 05/10/17, Staff B, the CEO, provided statistics for blood administration. In 2016, the lab released 74 units of blood, and in 2017 through 5/17, 32 units of blood.

The hospital's document titled "Monitoring Blood Administration Documentation to Ensure Accuracy" was reviewed. The compliance of monitoring of vital signs during blood administration was documented within this report and was as follows: 09/16= 0% compliance (blood was administered) , 11/16= 50% compliance, 12/16=70.5 % compliance, 01/17=50%, 02/17= 0% compliance (blood was administered) , 03/17= 57 % compliance, and 04/17= 0 % compliance (blood was administered) .

QAPI Minutes 02/08/17 through 04/17/17 were reviewed. The minutes documented discussions of compliance and improvement strategies for blood administration and documentation. Within the minutes, it was documented that the CNO stated she would be at the hospital at any time blood was given to ensure proper documentation and disciplinary action. However, blood administration errors occurred on April 18 and 19, 2017. The minutes documented a new VS flow sheet was approved.

QAPI Minutes 03/07/17 documented the CNO stated she would be at the hospital at any time blood was given to ensure proper documentation and disciplinary action. 05/12 17 at 12:30 pm, the surveyor requested evidence Staff T (Agency) was disciplined for the missing blood administration VS on 04/19/17. The incident report's closing remarks documented the CNO "spoke to" Staff T. The CNO stated the conversation was a verbal warning. There was no evidence the contracted agency was notified.

The 03/02/17 The Governing Body Minutes were reviewed and documented a new vital sign sheet created.

The 03/22/17 Governing Body Meeting Minutes were reviewed. The CNO stated a VS blood administration checklist was created to ensure staff complete documentation. The CNO stated she would be working 1:1 with all staff when blood was administered as well as developing competency. However, blood administration errors occurred on April 18 and 19, 2017.

0n 05/12/17, the CNO stated the quality and incident reporting information provided on 05/09/17 for blood administration was incorrect. The CNO then provided packets on containing vital sign information for 4 of the 12 patients in the incident log who received blood transfusions. The patients date of service were 02/08/17, 11/16/17, 04/07/17, and 04/20/17. There was no evidence of information provided to the Governing Body that the vital sign monitoring quality improvement effort data was incorrect.

The hospital's incidents reports for January 2016 through March 2016, and January through May 2017 were reviewed. The reports contained only an unique report number, but no patient identifier, and included "Closing Remarks" written by the CNO.
The February/ March 2016 reports contained the following 5 incidents involving blood transfusions:
~01/26/16 Unspecified staff failed to take VS per policy (no specific details) Closing Remarks: Staff counseled and educated
~02/02/16 Unidentified staff administered 2 units of blood without an ordered. Order read to type and cross. "Closing remarks: Educated and counseled"
~02/23/16 Staff P documented the 5 and 10 minute VS were within normal limits and only documented VS at 5 minutes "Closing remarks: Disciplinary action taken..."
~03/09/16 Staff P did not follow policy for the infusion of 2 units (no details provided) "Closing remarks: Disciplinary action taken..."
~03/16/17 Unidentified staff did not take 1 hour post transfusion vital sign. "Closing remarks: Nurse counseled"

The January 2017 through May 2017 incident reports contained the following 8 incidents documented involving blood transfusions:
~02/05/17 Staff S (Agency) gave 2nd unit of blood and VS blank. Blood Steering Committee working on new procedures.
~02/06/17 Staff U left blanks on VS sheet. On 2nd unit, VS were not taken per policy, and completion times on various documents did not match. Closing Remarks: Blood Steering Committee working on new procedures. All staff educated and nurse associated with occurrence no longer employed. All nurses reeducated and for future occurrences, employees to receive disciplinary action.
~02/06/17 Unidentified staff failed to take VS on 2nd unit of blood, and completion times on various documentation did not match.
~02/08/17 Unidentified staff left multiple blanks of VS in documentation. No pre-vital signs and for 2nd unit. 2nd unit of blood, and completion times on various documents did not match. Closing remarks: Discussed event with RN. New VS flow sheet for blood administration created and approved by the Governing Body on 03/22/17.
~02/22/17 Staff U wrote verbal order for type and cross. When questioned by peer, Staff U wrote verbal order for transfusion. There were 3 blanks in VS (unspecified times). Charge Nurse had instructed another nurse, Staff L, to transfuse the blood. Staff L stated lack of competence in transfusions to which the Charge Nurse responded saying a watched video equated to competency. "Closing remarks: Blood Steering Committee working on new program to ensure quality blood administration."
~04/07/17 Staff T (Agency Staff) administered 2 units of blood and #2 VS blank (and Lasix was not given)
~04/18/17 Staff V & Staff W did not take VS per policy- blanks in VS and Post VS not taken.
~04/19/17 Staff L, Staff T (Agency) and Staff X were involved with the administration of a total of 6 units of blood to a patient. Unspecified blanks noted in the VS documentation. Last unit did not have an order.. Closing remarks: Spoke to Staff T (Agency), who said the last unit was transfused by another staff peer.

The hospital's policy titled, "Blood/ Blood Components- Transfusion 11/19/15" was reviewed. The policy documented physician orders for transfusion should be verified. The policy directed staff to monitor vital signs (VS) blood pressure, temperature, pulse and respirations as follows:
~ every 5 minutes for the first 15 minutes, then (Note: 3 VS should be completed at 15 minutes)
~ every 15 minutes for the first 30 minutes, then
~ every hour until unit is infused, and
~ final set of vital signs following the completion of the transfusion, and
~ and 1 hr post transfusion.

The policy included a Blood Administration Form to be completed. The form had the following template for taking blood transfusion vital signs:
~ Start of transfusion (within 30 minutes of pre-VS) (Note: the policy did not require a starting set of VS), then
~ at 10 minutes (Note: the policy required at 5 minutes and 10 minutes VS) , then
~ at 15 minutes, then
~ at 30 minutes, then
~ at one hour, 2 hours, 3 hours, and 4 hours, then
~ VS at completion
~ 1 hour post transfusion

b. Competency

The personnel file for 2 of 2 agency nurse files (Staff R and Staff S) did not contain orientation and RN competency checklist. These files did not contain evidence of blood administration competency training administration of supplemental oxygen.

The personnel files for 3 of 10 employed staff files (Staff B, M, and Q) did not contain evidence of blood administration competency or training administration of supplemental oxygen.

The hospital had 3 competency checklists associated with blood administration. For the registered nursing staff, "Core Clinical Competency Validation- Position: Registered Nurse [the CNO stated this checklist was to be completed for Charge Nurses], "Initial ED/Critical Care and RN Competency Verification Form" [Note: The hospital did not have a CCU RN. The CNO stated the CCU RN was a nurse with greater experience.] and "RN Basic Competency Verification Form". The RN Basis Competency did not contain skills checklist for the administration of blood.

On 05/08/17 at 11:14 am, Staff B, the CNO, stated the hospital increased services to include the administration of total parental nutrition (TPN). [TPN is a method of getting nutrition through a vein.]. The hospital began to administer TPN services on February 3, 2017. From 02/03/17 to 05/12/17, 5 patients had received TPN infusions.

Twelve personnel files, and mutilple types of competency checklists for the nursing staff were reviewed. 11 of 12 staff (Staff H, Staff B, Staff M, Staff Q, Staff R, Staff S, Staff N, Staff K, Staff L, Staff AA, and Staff Z) failed to have a completed competency checklist of TPN administration in their personnel file.

The CNO stated she and 4 other staff (Staff N, Staff Y, Staff Z, and Staff CC) went to Carney Hospital for TPN training. The surveyors requested the date of the training, the name of the trainer, and the training verification, and none was provided The hospital document titled "TPN Administration Procedure Checklist" for Staff K was reviewed. The checklist was dated 02/03/17; yet, the CNO signed as preceptor on 02/02/17. Staff K's TPN checklist did not indicate if the training was actual or simulated. The CNO stated she and the 4 staff would serve as trainers for the other staff.

The hospital documents titled, "Medication Management Competency Verification Form", Initial ED/Critical Care and RN Competency Verification Form" [Note: The hospital did not have a CCU RN. The CNO stated the CCU RN was a nurse with greater experience.], "RN Basic Competency Verification Form" and the "The LPN Basis Competency " did not contain skills checklist for the administration of TPN.

A review of the "Heathlandweb Patient/ Chart showed Staff AA, an orientee, administered TPN to Patient # 29. No TPN competency was provided for Staff AA.

On 05/10/17 at 2:36 pm, surveyors observed Staff L perform TPN administration. Before connecting the IV bag to the PICC line, staff L scrubbed the hub but then laid the catheter tips on the patient bed re-contaminating them. Staff L connected the IV line to the PICC line without cleaning the hub after contamination. The CNO provided a competency checklist for Staff L for TPN.

On 07/25/16 a physician's order was written for patient #28 to receive 2 liters continuous oxygen via nasal cannula. On 07/27/16, Staff V switched the patient to 2.5 liters oxygen via mask without a physician's order or without notifying the physician of a change in the patient's condition. Staff V received a corrective action for violation of company policy and practicing out of a nurse's scope of practice.

An incident report was filed on 01/06/17 after respiratory therapy found that an unnamed swing bed patient had been receiving supplemental oxygen without a physician's order.

QA/PI minutes dated 02/08/17 stated staff education was necessary following and incident where an unnamed staff administered oxygen to a patient without a physician's order.

In March 2017, a medical event was reported when an order for supplemental oxygen was delayed to a patient that was short of breath. The patient had been connected to the medical air instead of the oxygen. On 05/10/17, the surveyor observed flow meters still active in each patient room.

A review of hospital policy was conducted. Hospital policy stated an order must be verified in the patient's medical record for the administration of supplemental oxygen.

See Tag 0336

a. Blood Administration
See Tag 0336 Item A

b. Competency
See Tag 0336 Item B




37609


c. Medication Safety & Security

Multiple dose Medications

QA/PI meeting minutes for March 8, 2017 and April 17, 2017 showed concerns with staff labeling Multiple Dose Vials (MDV) medications after opening, the action plan included staff checking each other to promote compliance. It was determined the hospital failed to evaluate the outcomes by the following findings:

See Tag 0276 Item E

Accountability for Controlled Substances

QA/PI meeting minutes for April 17, 2017 discussed narcotic shift counts completed in the Emergency department but no documentation and only 7 days of the narcotic shift counts completed on the medical surgical unit. No action plan was discussed in meeting and the status was classified as "informational".

See Tag O276 Item G

Pharmacy Secured and Limited Access

On 05/09/17 at 10:44 am, during a tour surveyors observed the pharmacy door unlocked and opened. The pharmacy is located in between 2 exit doors that lead to the outside.

See Tag 0276 Item B

Controlled Substance Discrepancies

See Tag O276 Item C

Stocked Medications on Patient Care Units

See Tag 0276 Item D

Patient's Home Medications

See Tag O276 Item F

See Tag 0342 and 0342 Item C



37609

b. Medication Safety & Security

See Tag 0342 Item C