HospitalInspections.org

Based on policy review, medical record review, and interview, the facility failed to administer a blood transfusion according to policy for 1 patient (#11) of 2 patients reviewed for blood transfusions.

The findings included:

Review of the facility's Blood, Blood Components-Transfusion policy, effective date 12/4/08, revealed, "...Two licensed nurses shall positively identify the patient by carefully comparing name and number on the patient's wristband with the information on the Transfusion Information sheet and the Blood/Blood Component unit: verify patient name; account number; birthdate; donor number...Donor Group-RH and Patient Group-RH type on blood bag label; and Expiration date; and identify the Blood Bank Ident-a-Blood number with the patient's blood band number...The fully completed Blood Transfusion Information Sheet is kept in the patient's record..."

Medical record review revealed Patient #11 was admitted to the facility on 7/16/15 with diagnoses including Pneumonia, Microcytic Anemia, Exacerbation of Chronic Obstructive Pulmonary Disease, and Atrial Fibrillation. The patient was discharged home on 7/20/15.

Medical record review of Patient #11's Blood Transfusion Information Sheet revealed the patient was administered a blood transfusion on 7/17/15. Further review of the Blood Transfusion Information Sheet revealed the unit of blood was identified by only 1 nurse on 7/17/15 at 3:36 PM. Further review revealed the blood transfusion was started on 7/17/15 at 3:38 PM, and in the area provided for documentation of "Date Finished...Time Finished...Amount Infused...," there was no documentation.

Interview with the nurse manager on 8/4/15 at 2:00 PM, in the Administration Conference Room, confirmed there was no documentation of 2 nurses identifying the blood transfusion prior to administration and no documentation of the time the transfusion was finished.

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Based on facility policy review, observation, facility record review, and interview, the facility failed to check the crash carts for outdated emergency medications for 1 of 3 crash carts reviewed.

The findings included:

Review of the facility policy Medication Distribution-Emergency Medication Supplies, dated 8/04, revealed "...the cart's...checked by a nursing staff member each day...entire contents of the crash cart are checked monthly for outdated...medications..."

Observation of crash cart #1 with the Registered Nurse (RN)/Charge Nurse, the Pharmacist, and the Chief Nursing Officer (CNO) on 8/3/15 at 12:30 PM, in the Medical-Surgical (Med-Surg) unit, revealed the following expired medications on the cart: 2 syringes of Epinephrine (used for cardiac stimulation) 1 milligram (mg)/10 milliliter (ml) expired 7/15; 2 bottles of Nitroglycerin (heart medication) 50mg/250ml in Normal Saline (volume expansion fluid) expired 7/15; and 1 liter of Lactated Ringers (volume expansion fluid) expired 12/14.

Review of the hospital's Crash Cart Check List for the Month of July 2015, revealed no entries for daily crash cart checks on 7/1, 7/13, 7/19, 7/20, 7/21, 7/22, and 7/23. Continued review revealed no pharmacy signature for "Cart restocked/checked by pharmacy" for the month of 7/15.

Interview with the RN/Charge Nurse, the Pharmacist, and the CNO on 8/3/15 at 1:30 PM, in the Med-Surg Unit, confirmed the facility failed to ensure the daily nursing check and the monthly pharmacy check for outdated medications of the crash cart.

Based on review of facility policy, medical record review, observation, and interview, the facility failed to provide a therapeutic Vancomycin dosing for one patient (#1) of one patient receiving the antibiotic.

The findings included:

Review of the policy and procedure titled "Clinical Activities Program-Pharmacokinetic Dosing Protocol for Vancomycin [antibiotic]," last revised February 2010, revealed, "INTENT: This policy has been developed to optimize Vancomycin therapy. Improper use...can result in either sub-therapeutic response...or an overdose...the pharmacist will determine the optimal dosing regimen...A random level should be drawn 24 hours after the first dose...PROCEDURE: 4. PHARMACIST'S ORDERS ON THE PATIENT'S CHART MUST CONTAIN: A. The calculated dose and interval..." Continued review of the Protocol revealed a Vancomycin Dosing Chart was included and revealed the interval of "Q [every] 24 hours" for patients with an "Actual Body Weight" of 66 kg (kilograms) to greater than 100 kg (adult weight).

Medical record review revealed Patient #1 was admitted on 07/31/15 at 4:06 PM, with diagnoses including Otitis Media, Alzheimer's Disease, and Altered Mental Status.

Review of the physician's orders dated 8/1/15 at 6:00 PM, revealed, "...Vancomycin IV [intravenously] per pharmacy protocol."

Review of an order dated 8/1/15 at 7:10 PM, revealed the order had been entered by the pharmacist and stated, "Vancomycin 1 Gm [gram] q [every] 18 hours in NS [normal saline] 250 ml [milliliters]. Vanc [Vancomycin] trough @ 0830 on 8-3-15."

Observation of Patient #1 on 8/3/15 at 3:15 PM, revealed Vancomycin 1 Gm was infusing into a peripheral intravenous (IV) catheter.

Medical record review of the patient's Medication Administration Record (MAR) revealed the patient had received a dose of Vancomycin at 9:00 PM on 8/1/15 and the next dose was given 37 hours later on 8/3/15 at 10:00 AM. Further review of the MAR revealed the initial Vancomycin order entered by the pharmacist did not include a timing interval designating when the second dose of Vancomycin was to be administered.

Interview with Licensed Practical Nurse (LPN) #3 on 8/3/15 at 3:25 PM, in the nursing station, revealed the infusion of Vancomycin began on 8/3/15 at 11:37 AM. Continued interview revealed the 10:00 AM dose began late due to the need for the pharmacist to come to the nursing unit and demonstrate how to properly mix a new delivery system (an enclosed and pre-measured Vancomycin dose to be mixed with 250 cc of NS).

Interview with the Director of the Pharmacy on 8/4/15 at 8:15 AM, in the conference room, revealed the pharmacist working the previous weekend was "not aware" of the 24 hour interval in the Vancomycin Protocol and stated, "Obviously the 24 hour protocol wasn't followed since it wasn't given on 8/2..." Interview continued and the Director commented the nursing staff had not questioned why there wasn't a Vancomycin dose to be given on 8/2/15, but then confirmed the weekend pharmacist had not entered an order for a Vancomycin dose to be given on 8/2/15.


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Based on facility policy review, observation, facility record review, and interview, the facility failed to maintain and inspect an emergency cart (crash cart) and defibrillator each shift for 2 of 3 crash carts observed; failed to maintain the sink in the central sterilizing department; and failed to maintain respiratory pediatric supplies in the respiratory department.

The findings included:

Review of the facility policy Medication Distribution-Emergency Medication Supplies, dated 8/04, revealed, "...the cart's...checked by a nursing staff member each day...entire contents of the crash cart are checked monthly..."

Review of the facility policy "Defibrillator" revised 5/28/10 revealed, "...The defibrillator is inspected and tested each shift to ensure it is working properly...check off that the defibrillator check was completed on the crash cart check list..."

Observation of crash cart #1 with the Registered Nurse (RN)/Charge Nurse, the Pharmacist, and the Chief Nursing Officer (CNO) on 8/3/15 at 12:30 PM, in the Medical-Surgical (Med-Surg) unit, revealed the cart contained the following expired blood vacutainers (tubes to collect blood samples): 2 red top tubes expired 12/13 and 12/14; 1 yellow top tube expired 11/14; 4 purple top tubes expired 11/13, 2/14, 4/15; 2 green top tubes expired 4/14; 2 tiger top tubes expired 9/14; and 4 blue top tubes expired 2/14. Further observation revealed the cart contained the following expired emergency supplies: 1 triple lumen catheter (used for intravenous access) expired 4/11; 1 scalpel expired 6/14; and 2 25-gauge intravenous needles expired 9/14. Further observation of the crash cart revealed a log for checking the defibrillator and the log indicated the crash cart and the defibrillator had not been checked on 7/1/15, 7/13/15, 7/19/15, 7/20/15, 7/21/15, 7/22/15, and 7/23/15. Continued review revealed no pharmacy signature for "Cart restocked/checked by pharmacy" for the month of 7/15.

Interview with the Charge Nurse on 8/3/15 at 12:35 PM, at the crash cart, confirmed the defibrillator was to be checked each shift.

Observation of crash cart #2 with the RN/Charge Nurse, the Pharmacist, and the CNO on 8/3/15 at 1:20 PM, in the Med-Surg Unit, revealed the cart contained 1 tracheostomy tube (plastic tube inserted into the neck to create an emergency airway), expired 8/13.

Interview with the RN/Charge Nurse, the Pharmacist, and the CNO on 8/3/15 at 1:30 PM, in the Med-Surg Unit, confirmed the hospital failed to ensure the daily nursing and the monthly pharmacy check for outdated emergency supplies for 2 of 3 crash carts.

Interview with the Chief Compliance Officer on 8/3/15 at 1:30 PM, at crash cart #1, confirmed the cart and defibrillator had not been checked.

Observations of the central sterilizing unit on 8/3/15 at 2:30 PM, revealed the wash sink used to rinse surgical instruments after washing did not have a plug for the drain. Continued observations revealed Licensed Practical Nurse (LPN) #2 was unable to immerse the cleaned instruments in clean water to rinse.

Interview with LPN #2 on 8/3/15 at 2:30 PM, in the central sterilizing unit, confirmed the wash sink did not work properly and rinsing the surgical instruments was difficult without immersing them in clean water.



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Observation with Respiratory Therapist #1 on 8/3/15 at 3:00 PM, in the Respiratory Department, revealed a bin containing 15 pediatric nonrebreather masks (used for delivery of high concentrations of oxygen) with 8 masks expired 8/13 and a bin with 1 pediatric venturi mask (used for delivery of high flow enriched oxygen at a settable concentration) expired 4/14.

Interview with Respiratory Therapist #1 on 8/3/15 at 3:30 PM, in the Respiratory Department, confirmed the facility failed to monitor the expiration dates of the pediatric respiratory equipment.

Based on facility policy review, observation, and interview, the facility personnel failed to wear appropriate attire in the Operating Room and failed to follow hand hygiene procedures during 1 of 1 blood glucose testing.

The findings included:

Review of the facility policy Attire in the Operating Room (OR), effective date 12/4/08, revealed, "...All reusable attire shall be laundered after each use, by a laundry facility approved and monitored by the hospital..."

Observations of OR #1 on 8/3/15 at 12:45 PM to 1:45 PM, revealed surgeon #1 performing surgery on patient #12 while wearing a reusable surgical hat.

Interview with surgeon #1 on 8/3/15 at 3:00 PM, in the OR nurses station, confirmed his surgical hat was reusable and that he laundred his surgical hats at home.

Interview with the facility's infection control nurse on 8/4/15 at 9:00 AM, in the Infection Control Office, revealed all reusable surgical attire, including hats, must be laundred after each use in the hospital's contracted laundry.

Review of a facility policy "Proper Handwashing Technique-Hand Hygiene" revised August 2014, revealed "according to CDC (Centers for Disease Control) guidelines, all personnel are required to use the following hand hygiene technique for using non-antimicrobial soap and water, or an alcohol based rub...This is to be done at the following intervals...always after removing gloves..."

Observation on 8/5/15 at 12:00 PM, at the nursing station, revealed Licensed Practical Nurse (LPN) #1 preparing to obtain a blood glucose. LPN #1 entered the patient's room, washed the hands, and donned gloves in preparation for obtaining the blood glucose. Continued observation after the blood glucose was obtained revealed LPN #1 left the patient's room without removing the gloves, went to the nursing station, cleaned the blood glucose monitor, and then removed the gloves. LPN #1 then used the computer before going to the medication room to get insulin to give to the patient. LPN #1 then took the insulin to the patient's room, washed her hands, donned gloves, administered the insulin, removed the gloves, and went back to the medicine room.

Interview with LPN #1 on 8/5/15 at 12:15 PM, in the medicine room, confirmed the LPN did not perform hand hygiene after removing the gloves following obtaining the blood glucose and after giving the insulin.

Based on medical record review and interview, the facility failed to document the discharge planning evaluation in the medical record for one discharged patient (#4) of two closed records reviewed.

The findings included:

Medical record review revealed Patient #4 was admitted to the facility on 7/13/15 with diagnoses including Tietze's Disease (an inflammatory condition in the chest wall) and Multiple Sclerosis. Medical record review revealed the patient was discharged to home on 7/16/15.

Review of the Initial Physical Assessment dated 7/13/15, revealed, in response to the question Community Resources Currently Used, "Home Health Agency: At Home Health."

Medical record review and interview with the Case Management Director on 8/4/15 at 10:50 AM, in the conference room, confirmed no documentation of a discharge plan was included. Interview continued at 11:00 AM, after the Director returned from her department with a copied page from the patient's medical record titled "Record of Admission." The Director stated the page had been filed in the Case Management department. Review of the copied page revealed a handwritten notation, "07/14/15 pt [patient] states had HH [home health] in past, states no needs at this time." Further interview revealed one of the facility's three Case Managers rounded with the physician or the physician extender daily, reviewing each patient. Interview confirmed the rounding and the results of the discharge planning evaluations were not routinely documented in the individual medical records.