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Based on observation, review of medical records (MR), facility policies and procedures, and interview with staff, it was determined the facility failed to ensure the staff:

a) Administered as needed (PRN) medication to patients per physician orders.

b) Documented the patient's response to PRN medication administration.

c) Physician's orders were complete and accurate.

d) Provided and documented wound care as ordered for 1 of 1 wound records reviewed.

e) Documented wound care and skin assessments per policy.

This affected Patient Identifier (PI) # 3, 1 of 1 wound care record reviewed, and had the potential to negatively affect all patients served by this facility.

Findings include:

Facility policy:
Subject: Ordering of Medication
Policy #: CTS 3.1
Update: 3/18

Procedure:

"1. All medications to be dispensed must be ordered or approved by ...physician ...
2. Orders will be documented as follows:
... The order will list the name of the medication ordered, the dosage, the frequency and time limitedness of the medications ...
When PRN medications are prescribed, indication for use must be specific in the written order ...."

Facility Policy:
Medication Storage, Control, and Assistance and Administration
Policy #: CTS 3.0
Update: 3/18

Policy:

"Consumers receiving treatment...

C. Medication Administration/ Assistance...

8. Altapointe Health Inc. (AH) qualified staff must document information related to a consumer receiving PRN and over the counter medications including: date, name of consumer, compliant, name of medication received, amount of medication given, time of medication administration, and results..."

Facility Policy
Subject: Physician Orders
Policy #: CTS 3.0.3
Updated: 3/18

Policy:

"In accordance... only medical staff duly authorized shall write physician orders... All orders shall be recorded and authenticated.

Procedure:...

2. A physician's order shall be written clearly and shall be complete...

3. Physician's orders are required for admissions, discharge, medications, treatments..."


Facility Policy
Subject: Wound Management and Dressing Changes
Policy #: CTS 3.3.7
Revised: 11/13

Policy:
"Medical staff including physicians, ..., and nursing staff assess consumer's skin integrity as indicated ...

Assessment and documentation of a wound include but is not limited to the following information:

- Location of wound
- Length/ width/depth of wound
- Wound base (pink, red, yellow, black, or green)
- Exudate (serous, bloody, purulent)
- Odor
- Sensation and pain ...

Wound Care Interventions:
1. Each consumer will be assessed for skin integrity at the time of admission ...

2. A plan of care will be initiate as indicated ..."

1. PI # 3 was admitted to the facility on 5/1/18 with diagnoses including Schizoaffective Disorder and wound to right lower extremity.

Review of the 5/1/18 Skin Assessment Tool and admission revealed documentation of "8 inch tall open wound on right lower leg."

Review of the daily nursing documentation dated from 5/1/18 to 6/8/18 revealed no documentation of complete description of right leg wound that included the length, width, depth of wound or the drainage of the wound.

Review of physician's order dated for 6/8/18 for Wound # 1 Right Anterior Lower Leg revealed "cleanse wound with liquid anti-bacterial soap and water prior to dressing change. Rinse well with warm water or Normal Saline (NS). Pat dry. Apply Viscopaste strips double layer over wound. Twice a day and PRN. Cover with 6 abdominal (ABD) pads, Kerlix, and tape to secure.

Compression/Edema Control...
Remove compression stocking every night before going to bed and put on every morning prior to getting up out of bed..."

Review of the 6/9/18, 6/10/18, 6/11/18, 6/12/18, 6/13/18, 6/14/18, 6/15/18, 6/16/18, 6/17/18, 6/18/18, 6/19/18 twice daily Nursing Progress Notes (22 total) revealed no documentation that wound care was provided or if compression stockings were used as ordered.

Further review of the above mentioned 22 Nursing Progress Notes revealed no documentation the nurse measured the wound for length, width, depth, description of drainage.

The staff failed to document wound assessment and provide the wound care as ordered.

Review of the EMAR (Electronic Medication Administration Record) printed on 6/20/18 revealed an order dated 5/18/18 at 11:17 PM for Benadryl (Diphenhydramine Hydrochloride) 50 mg (milligrams) every 6 hours as needed for agitation and/or EPS (Extrapyramidal Symptoms.)

Review of the eMAR dated 5/18/18 at 11:30 PM and 5/20/18 at 1:05 AM revealed Benadryl was administered and no reason was documented. There was no documentation provided to the surveyor, if the PRN medication was effective or the patient's response.

Review of the eMAR 6/3/18 revealed that Benadryl 50 mg was administered at 6:43 AM and again on 6/20/18 at 1:14 AM for wound itching.

There was no physician's order to administer the Benadryl for itching.

Review of the 6/19/18 nursing documentation revealed PI # 3 received Norco 7.5 mg at 9:54 AM for pain 8 out of 10. There was no documentation the staff reassessed the patient's pain after administering pain medication.

In an interview conducted on 3/21/18 at 1:00 PM with Employee Identifier # 6, Nurse Coordinator, confirmed the above findings.

Based on review of the facility's policies and procedures, observations, and interviews it was determined the facility failed to ensure all expired medications were removed and not available for patient use. This had the potential to negatively affect all patients served by this facility.

Findings include:

Policy: MM 1.5
Subject: Disposition of Unused Medications
Revised Date: 4/2017

"Policy:

To ensure the safety of consumer, staff and others, an appropriate means of disposal of unused prescribed and stock medications is necessary. The method of disposal will at all times be in accordance with AltaPointe Health, Inc. (Incorporated) (AH) pharmacy guidelines.

Procedure

4. The contracted disposal company will deliver containers that will be placed in each program's designated area and will be utilized to discard expired and unused medications. The pharmacy technician at hospitals will make rounds to medication storage rooms and remove unused and expired medications and store them in the containers in the locked hospital pharmacy."

Facility Policy:
Medication Storage, Control, and Assistance and Administration
Policy #: CTS 3.0
Update: 3/18

Policy:

"Consumers receiving treatment...

E. Storage of Medication

3. All medication must be in prescription bottles, daily medication boxes or cards labeled exactly as on the MAR (Medication Administration Record)..."

1. A tour of the facility pharmacy was conducted on 6/19/18 at 11:25 AM with Employee Identifier (EI) # 3, Pharmacist.

The surveyor observed the following expired medications on the pharmacy shelves and available for patient use:

Suboxone 2 mg (milligrams)/0.5 mg 1 box containing 30 pouches of individual doses with expiration date of 3/2018

Brexpiprazole 4 mg bottle, with a pharmacy prescription label containing an unsampled patient name on bottle that is not a current or discharged patient of facility, with an expiration date of 3/15/18.

Lamictal 25 mg bottle, with a pharmacy prescription label containing an unsampled patient name on bottle that is not a current or discharged patient of facility, with an expiration date of 8/19/16.

Lamictal 25 mg bottle with a pharmacy prescription label containing an unsampled patient name on bottle that is not a current or discharged patient of facility, with an expiration date of 5/27/16.

Lamictal 25 mg bottle, with a pharmacy prescription label containing an unsampled patient name on bottle that is not a current or discharged patient of facility, with expiration date of 5/29/16.

Lamictal 25 mg bottle, with a pharmacy prescription label containing an unsampled patient name on bottle that is not a current or discharged patient of facility, with an expiration date of 8/17/16.

Calcium Carbonate 60 mg with D 3 400 IU (international unit), 3 single dose units with expiration date of 5/2018.

Verapamil Hydrochloride 120 mg, 9 single dose units with expiration date of 6/8/18.

Rexulti 3 mg bottle, with a pharmacy prescription label containing an unsampled patient name on bottle that is not a current or discharged patient of facility, with an expiration date of 9/16/17.

Rexulti 0.5 mg bottle, with a pharmacy prescription label containing an unsampled patient name on bottle that is not a current or discharged patient of facility, with an expiration date of 11/04/17

Fanapt 1 mg bottle, with a pharmacy prescription label containing an unsampled patient name on bottle that is not a current or discharged patient of facility, with an expiration date of 4/17/18.

The previous findings were verified by EI # 3, Pharmacist, for expiration dates prior to surveyor leaving pharmacy.

An interview was conducted with EI # 3 on 6/19/18 at 12:00 PM, about bottles with pharmacy prescription label containing an unsampled patient's name on the bottles. EI # 3 verbalized that the pharmacy gets medications from Integrated Healthcare Pharmacy, which has a patient assistance program, that the patient's did not pick up or were discontinued prior to using the prescription. EI # 3 further verbalized that she/he then puts the medications with pharmacy label from Integrated Healthcare, on the facilities pharmacy shelf and will repackage just prior to them going to the nursing units.

An interview was conducted with EI # 2, Administrator, on 6/20/18 at 1:00 PM about bottles with a pharmacy prescription label containing a patient's name on the bottles that are not current or past patients of the facility located in the pharmacy and available for patient use. EI # 2 verbalized that the facility does receive medications that are non formulary for facility from Integrated Healthcare Pharmacy. EI # 2 verbalized that Integrated removes the patient(s) label then delivers medication to be repackaged at facility.

Based on the previous, the pharmacy staff failed to remove expired medications from pharmacy and follow facility procedure, as verbalized by EI # 2, Administrator, at an interview on 6/20/18 at 1:00 PM, for use of medications from Integrated Healthcare Pharmacy.

2. A tour of the facility 200 unit was conducted on 6/21/18 at 10:15 AM.

The surveyor observed the following expired medications and supplies in the emergency crash cart, located in the nursing station, and available for patient use:

Dextrose 5 % (percent) in 1000 ml (milliliters) Lactated Ringer's, 2 bags, with expiration dates of 11/17.

Non-Conductive Connecting Tube with an expiration date of 01/2013.

An interview was conducted on 6/21/18 at 1:50 PM, with EI # 9, Nurse Coordinator, who confirmed the above findings.



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3. A tour of the Unit 400 medication room was conducted on 6/19/18 at 12:45 PM with EI # 7, Licensed Practical Nurse (LPN), and revealed the following in the Home Medication Cabinet:

1- 10 ml open vial of Lidocaine 1% 100 mg/ 10 ml labeled with 5/12 as the date opened. The staff failed to discard after 28 days after opening.

1- A medication bottle with a yellow sticky note and labeled, "XXXX (last name of an unsampled patient), Ingrezza 40 mg 1 tablet until gone." The staff failed to ensure all medications were labeled with the start date, the ordering physician and who labeled the medication bottle.

4- bottles of medications of discharged patients were found in the cabinet.

The above findings were confirmed in an interview conducted on 6/19/18 at 1:15 PM with EI # 6, Nurse Coordinator.

Based on United States Health Public Food Code 2009 regulations, observations and interview, it was determined the hospital failed to ensure expired foods were not available for patient use and food was stored in a safe and sanitary manner.

This had the potential to negatively affect all patients.

Findings include:

United States Health Public Food Code 2009

3-501.17 Ready-to-Eat, Potentially Hazardous Food
(Time/Temperature Control for Safety Food),
Date Marking.
...commercially processed food open and hold cold
(B) Except as specified in (D) - (F) of this section, refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety...

(C) A refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) ingredient or a portion of a refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) that is subsequently combined with additional ingredients or portions of food shall retain the date marking of the earliest- prepared or first prepared ingredient.

(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include:...
(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section...

A tour of the Dietary Department was conducted on 6/20/18 at 10:15 AM with Employee Identifier (EI) # 8, Dietary Manager.

During the tour the dry storage area was observed and the following expired/undated/unsealed items were found:

2 - 5 pound (lbs) bags of Quaker grits were marked with a received date of 5/16/18 and the expired date on each bag was 4/23/18.

1 - 5 lb bag yellow cake mix was opened and not sealed properly and no open date was marked on the bag.

In the dry storage was a large bin with stored flour. In the storage bin in the flour was a large clear plastic bowl used for scooping out the flour. All scoops for flour or sugar are not to be stored inside the bin due to sanitation issues.

During the tour the large walk in refrigerator was observed. The following food items were observed to not have open dates or were expired:

1 - 128 ounce (oz) of pepperoncini peppers opened with no open date.

1 - 1 gallon Worcestershire sauce opened with no open date.

1 - 32 oz bottle of lemon juice opened with no open date.

1 - gallon bottle of sweet and sour sauce opened with no open date.

1 - gallon bottle of soy sauce opened with a date received of 1/12/18, no open date and an expected expire date of 6/12/18.

1 -50.5 oz bottle of Heinz Ketchup opened with no open date.

1 - gallon jug of Mayonnaise opened with a received dated of 5/24/18 and no open date.

An interview was conducted on 6/20/18 at 11:00 AM with EI # 8, who confirmed the above mentioned findings.

Based on review of facility policy, Glucometer/Quality Control Logs, observation, and interview, it was determined the facility failed to ensure that:

a) All medical supplies available for patient use in the facility were not expired.

b) Controls for glucometers were performed and logs were maintained per policy.

c) Food available for patients were not expired.

This had the potential to affect all patients served by the facility.

Findings include:

Facility Policy
Subject: Care and Use of Blood and Glucose Monitoring Device
Policy: PE: 2.2
Revised Date: 8:15

"Policy...

The blood glucose monitoring device...

6. Control testing ensures that the meter and the test strips are working properly and giving reliable results. Control tests should be run when:

-According to the manufacturer's instructions.

Glucometer/Quality Control Check Instructions
Revised 2/1/13

"1. Read...

2. New bottle (not box) should be dated when opened and with 90 day expiration, and initialed.

3. Complete high Hi Value and Low value on separate lines.

4. Check serial number on monitor to make sure it has not been switched out..."

1. During a tour of the medication room conducted on 6/19/18 at 12:45 PM with Employee Identifier (EI) # 7, Licensed Practical Nurse (LPN), the surveyor observed the following supplies to be expired:

4- 236 milliliter (ml) containers of milk with the use by date of 6/18/18.
4- stained boxes of Colostomy supplies with the expiration dates of 12/17 and 3/18.
6- blue top blood vials with the expiration dates of 4/30/18.

The following were opened and not labeled with open date or initials:

1- bottle of glucometer quality control for High level.
2- bottle of glucometer quality control for Low levels.

Review of the Glucometer Quality Control Checks (Log) for June 2018 revealed the only lot number/ code listed as 497114. Review of the control numbers on bottles and strips revealed different numbers.

The surveyor asked EI # 6, Nurse Coordinator, to identify the documented lot number, and he/she could not identify the number documented in the log.

Further review of the Glucometer Quality Control Log revealed the daily High and Low levels were blank: 6/8/18, 6/9/18, and 6/15/18.

EI # 6 confirmed the staff failed to perform/ document daily controls for the glucometer.

The surveyor noted an open gray bath basin on top of the medication room counter labeled with a patient's name. The basin contained wound care supplies including a 500 ml bottle of Normal Saline and not labeled with the open date.

In an interview conducted on 6/19/18 at 1:30 PM, EI # 6, Nurse Coordinator, confirmed the above findings.

Based on review of Siemens Technology Report, observations and temperature logs it was determined the facility failed to ensure all refrigerator temperature logs within the facility contained complete and accurate temperature documentation.
This had the potential to negatively affect all patients served by the facility.

Findings include:

Siemens Technology Report
March, 2007
Siemens Industry, Inc. Page 1 of 6
Healthcare Facilities-Good Storage Practices
Monitoring Controlled Environments

Good Storage Practices
Pharmaceutical products include required storage conditions on their labeling. These are the conditions under which the expiration date is applied. The storage requirements specified on the product label must be observed throughout the distribution of the
pharmaceutical product. Label temperature warnings reflect the results of real-time storage tests. USP <1079> provides general guidance concerning the storage of pharmaceutical products.

Cold Storage-Medicinal products labeled for cold storage are stored in a refrigerator where the temperature cannot exceed 8°C (46°F). Domestic
refrigerators are not suited for medicinal products because they do not have the precise control necessary to maintain temperature between 2°C and
8°C (36°F and 46°F).

Cool Storage-Medicinal products labeled for cool
storage are stored in a cool place where the temperature is between 8°C and 15°C (46°F and 59°F).

1.On 6/21/18 at 9:00 AM a review of the temperature logs for the galley and consumer nutrition refrigerators revealed the following temperature ranges printed on the log:

The refrigerator temperature for food (galley) should be kept between 34 - 40 degrees and 36 - 46 degrees for medications.

Review of the temperature logs for the refrigerators on units 200, 300 and 400 revealed the following temperatures not within range:

Unit 200 for June 2018 Galley refrigerator:

June 2-3: temperature 43 degrees
June 4: temperature 44 degrees
June 9: temperature 43 degrees
June 10 - 11: temperature 44 degrees
June 12: temperature 43 degrees
June 13 -18: temperature 45 degrees

Unit 300 March 2018 Galley refrigerator:

No temperatures documented on March 30th.

Unit 300 April 2018 Galley refrigerator:
No temperatures documented on the 12 th.

Unit 300 June Galley refrigerator:

No temperatures documented on the 10 th, 15 th and 16 th.

Unit 400 March Galley refrigerator:

June 1: 42 degrees
June 6: 42 degrees
June 8 - 9: 41 degrees
June 10: No documentation of temperatures.
June 14: 41 degrees
June 20: 45 degrees
June 21 - 22: 42 degrees
June 23: 41 degrees
June 24: 44 degrees
June 25 - 26: 42 degrees

Unit 400 June 2018 Consumer Nutrition refrigerator:

June 2: 42 degrees
June 3: 41 degrees

Unit 400 June 2018 Galley refrigerator:

June 5: 41 degrees
June 15 - 18: 42 degrees
June 19: 44 degrees.

Review of all the temperature logs revealed no documentation of actions taken to resolve the issue for the increase in temperatures.

An interview was conducted on 6/21/18 with Employee Identifier # 1, Director of Quality Assurance, who confirmed the above mentioned findings.

Based on observations, review of policies and procedures and interviews, it was determined the staff failed to:

a) Perform hand hygiene per policy.

b) Maintain clean surfaces in patients room and the facility medication cart after contact with contaminated medical equipment.

c) Wear appropriate personal protective equipment (gloves) when cleaning contaminated surfaces.

This affected Patient Identifiers (PI) # 3 and had the potential to negatively affect all patients served by the facility.

Finding include:

Facility policy
Subject: Hand Hygiene
Policy #: IC 3.2
Update: 3/18

Policy:

"All ...employees are responsible for appropriate hand hygiene.

...Procedure:

Indications for hand hygiene:

Before and after any consumer (patient) procedure
...Before handling food and medications...
After contact with inanimate objects or medical equipment close to consumer

After removal of gloves..."

Facility Policy:
Subject: Wound Management and Dressing Changes
Policy #: CTS 3.3.7
Revised: 11/13

Policy:
"Medical staff including physicians, ..., and nursing staff assess consumer's skin integrity as indicated ...

Assessment and documentation of a wound include but is not limited to the following information...
2. A plan of care will be initiate as indicated ...

Dressing Change Protocol

1. Removal of old dressing (always follow Standard Precaution procedure).
a. Wash hands. Don gloves ...
b. ...Discard dressing...
d. Remove and discard gloves and wash hands again.
e. Don gloves...

2. Putting on New Dressing
a. If order states to cleanse the wound, always clean from the center of the wound away to the outside of wound. Wipe outward only once. Do not go over the same area of the would with the cleansing applicator...
e. Wash hands."

Policy #: IC 3.7
Subject: Cleaning of Patient Care Equipment and the Environment
Update: 3/18

Policy:

Each AltaPointe Health...program will ensure that the environment is maintained in a clean and sanitary condition. The accumulation of dust, soil, and microbial contaminants on environmental surfaces is both aesthetically displeasing and a potential source of health-care associated infections. The overall responsibility for infection prevention and control, resides with the Infection Prevention Practitioner...

Procedure:

3. Employees are responsible for cleaning/sanitizing consumer equipment between uses.
7. Equipment cleaning guidelines include:

B. Automated vital sign machines

i. Disinfect with a Sani-cloth after each consumer use.
ii. Clean blood pressure cuff with a Sani-cloth between consumer use.

C. Stethoscope:

i. Wipe with alcohol or Sani-cloth after each consumer use...

K. Medication Room Pill Splitter
i. The pill splitter must be wiped with an alcohol pad between use to prevent cross-contamination..."

1. PI # 3 was admitted to the facility on 5/1/18 with diagnoses including Schizoaffective Disorder and wound to right lower extremity.

Review of physician's order dated for 6/8/18 for Wound # 1 Right Anterior Lower Leg "cleanse wound with liquid anti-bacterial soap and water prior to dressing change. Rinse well with warm water or Normal Saline (NS). Pat dry. Apply Viscopaste strips double layer over wound. Twice a day and PRN (as needed). Cover with 6 abdominal (ABD) pads, Kerlix, and tape to secure."

An observation of care was conducted on 6/20/18 at 11:05 AM with Employee Identifier (EI) # 7, Licensed Practical Nurse (LPN) to observe wound care for PI # 3.

The surveyor observed a gray plastic bath basin labeled with PI # 3's name that was open on the counter of medication room. The surveyor asked EI # 7 what it was. He/she stated "It is PI # 3's wound care supplies. We take it with us when we do wound care." The surveyor noted several pair of loose gloves in the basin along with the supplies.

EI # 7 entered and awoke PI # 3 from sleep and emptied the basin of wound care supplies and gloves on PI # 3 room mates shelf.

EI # 7 cleaned the scissors with a Santiwipe and gave the scissors to PI # 3 who laid the scissors directly on the night table shared with room mate.

EI # 7 discarded his dirty gloves and removed a "clean" pair of gloves from his pants pocket and applied the gloves. EI # 7 failed to perform hand hygiene before re-applying gloves.

PI # 3 removed the dirty dressing from right lower leg with ungloved hands.

EI # 7 failed to instruct PI # 3 to wash hands before beginning or wear gloves while performing wound care.

EI # 7 filled the bath basin with water and placed with in reach of PI # 3, along with a wash cloth. PI # 3 took the wash cloth and with bare /ungloved hands moistened the wash cloth and then applied liquid anti-bacterial soap and began cleanse the wound over and over with the wash cloth. EI # 7 instructed PI # 3 to make sure all of wound was cleaned.

PI # 3 then rinsed the cloth out with the water and then applied the anti-bacterial soap directly on the wound and cleaned again with the same wash cloth and un-gloved hands.

EI # 7 discarded the dirty water in gray basin and went out side the room to speak to another staff member, wearing the same dirty gloves.

EI # 7 instructed PI # 3 to use the Spray NS to rinse the wound, PI # 3 sprayed the NS on the wound and then blotted the wound with the wash cloth.

After PI # 3 completed the dressing change, EI # 7 with the same dirty gloves cleaned the basin with a Saniwipe, and replaced the un-used dressing supplies and un-used gloves to the gray basin.

EI # 7 removed the dirty gloves and left PI # 3's room, opened the nursing station door, and then door to the medication room and placed the gray basin on the counter of medication room. EI # 7 failed to perform hand hygiene after removing dirty gloves.

In an interview conducted on 6/20/18 at 12:10 PM EI # 6, Nurse Coordinator, confirmed the above findings.



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2. An observation was conducted of the Dietary Department on 6/20/18 at 11:25 AM to observe preparation and plating of food.

Dietary staff washed hands and donned clean gloves. Salads were placed in disposable containers and placed on patient trays. EI # 9, dietary staff, with the same gloves on then began to check the temperatures of each food item and document the temperatures on the log.

EI # 8, Dietary Manager, was assisting on the serving line after washing hands and donning clean gloves. While on the serving line EI # 8 removed gloves and entered kitchen to obtain a container of food for the plating. EI # 8 failed to wash hands after removing gloves. EI # 8 donned a clean pair of gloves after placing the food on the serving line and did not wash hands prior to donning clean gloves.

At 11:35 AM EI # 9 began plating the food without changing gloves and washing hands and donning a new pair of gloves.

EI # 8 removed gloves and donned clean gloves without washing hands and began to check the temperature of the chicken and placed lids on the the plates.

EI # 8 after placing all the food containers on the serving line for the patients and employees EI # 8 removed gloves and donned clean gloves without washing hands and began serving employees their food.

An interview was conducted on 6/21/18 at 2:30 PM with EI # 1, Director of Quality Assurance and EI # 2, Administrator, who confirmed the above mentioned findings.



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3. A injection administration observation was performed on 6/21/18 at 11:50 AM with EI # 5, RN (Registered Nurse). The medication was administered to an unsampled patient.

During the observation, EI # 5 performed hand hygiene in the medication room at the nursing station using soap and water. After performing hand hygiene EI # 5 verified medication order on the computer using bare hands and computer keyboard/mouse to verify medication order.

After the medication order was verified on computer, EI # 5 then removed pre-measured Invega 234 mg IM (Intramuscular) dose syringe from box and attached enclosed needle to syringe without performing hand hygiene. EI # 5 then obtained a pair of gloves and an alcohol wipe in the nursing station and proceeded to the patient's room. EI # 5 failed to perform hand hygiene prior to leaving nursing station.

EI # 5 entered the patient's room, donned gloves, and administered the Invega injection. EI # 5 failed to perform hand hygiene prior to gloves being donned and administration of the injection.

During an interview on 6/21/18 at 1:58 PM EI # 9, Nurse Coordinator, confirmed the RN failed to perform hand hygiene per facility policy.

Based on review medical records (MR) and facility staff interviews, it was determined the nursing staff failed to follow the physician's order for administration of as needed medication(s).

1. PI (Patient Identifier) # 8 was admitted to the facility on 6/18/18 with the diagnosis of Schizoaffective Disorder, Bipolar Type.

Review of the current medication orders and physician's order form in EMR (electronic medical record) revealed a physician's order dated 6/18/18 at 1:55 PM for Benadryl (Diphenhydramine Hydrochloride) 50 mg (milligrams) every 6 hours as needed for agitation and/or EPS (Extrapyramidal Symptoms.)

Review of the eMAR (electronic Medication Administration Record) dated 6/19/18 revealed that Benadryl 50 mg was administered at 11:39 PM with the following comment/reason: Requested for sleep...

Based on the previous, the facility staff failed to administer as needed medication per the physician's order.

In an interview on 6/21/18 at 1:50 PM, Employee Identifier (EI) # 9, Nurse Coordinator, confirmed the above findings.



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2. PI # 3 was admitted to the facility on 5/1/18 with diagnoses including Schizoaffective Disorder and wound to right lower extremity.

Review of the EMAR printed on 6/20/18 revealed an order dated 5/18/18 at 11:17 PM for Benadryl 50 mg every 6 hours as needed for agitation and/or EPS.

Review of the eMAR dated 5/18/18 at 11:30 PM and 5/20/18 at 1:05 AM revealed Benadryl was administered and no reason was documented. There was no documentation provided to the surveyor, if the PRN medication was effective or the patient's response.

Review of the eMAR 6/3/18 revealed that Benadryl 50 mg was administered at 6:43 AM and again on 6/20/18 at 1:14 AM for wound itching.

There was no physician's order to administer the Benadryl for itching.

In an interview conducted on 3/21/18 at 1:00 PM with EI # 6, Nurse Coordinator, confirmed the above findings.