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Based on observation, interview, and policy review, the provider failed to ensure outdated medications in one of one pharmacy refrigerators were not available for patient use. Findings include:

1. Observation and interview on 7/22/14 at 9:00 a.m. with pharmacist F revealed:
*Their pharmacy had a refrigerator that contained all medications that required refrigeration.
*The top two shelves of the refrigerator had medications that were still in use.
*The bottom shelf of that refrigerator had refrigerated medications that had expired and were waiting to be returned to the wholesaler.
-There was not any sign indicating any medications in the refrigerator had expired.
-On that same shelf with the expired medications was chemotherapy medications which had not expired.
*Medications that had expired were:
-Integrelin (treatment of acute coronary syndrome).
-Tetanus (vaccination).
-Hepatitis B (vaccination).
-Diltiazem (treatment for hypertension)
-Hepatitis vaccine (vaccination).
-Decavac (vaccination).
-Influenza vaccine (vaccination).
*All of the above medications had expired in May 2014 and June 2014.
*He kept those outdated medications until the wholesaler came to pick up "medications waiting to be returned."
*December was that next scheduled wholesaler visit.
*He had not known where else to store expired medications that required refrigeration.
*When the pharmacist was not available the licensed nurses could access medications in the pharmacy.
*He agreed there was a risk of using the expired medications when they were stored with medications that were still in use.

Review of the provider's July 2006 pharmacy department policy revealed:
*"Outdated medications will not be allowed to remain in the Pharmacy, the Medication Room dispensing area, or in patient care areas for patient use."
*Outdated items will be isolated from dispensing stocks by storing them in a designated area of the Pharmacy."

Based on observation, interview, record review, and policy review, the provider failed to ensure:
*Appropriate hand hygiene and glove use during two of two medication (med) administration observations by two of two registered nurses (RN) (A and B) for two of two sampled patients (2 and 31) on the in-patient floor.
*The test strip for testing Metricide OPA plus (a high-level disinfectant) was dated and used within the manufacturer's directions.
*Two of two electric razors used for multiple patients was cleaned and disinfected in-between each patient use.
*Foam positioning wedges were cleaned between patient use in one of one radiology room and one of one computed tomography (CT) room.
Findings include:

1. Observation on 7/22/14 at 9:30 a.m. with RN A during an intravenous (IV) Solu-medrol administration for patient 2 revealed she:
*Drew up from the medication ampule ( med container) into a syringe.
*Entered the patient's room with the med.
*Administered the med per the patient's IV port.
*Had not washed or sanitized her hands prior to or after the administration of the med.

2. Observation on 7/22/14 at 10:30 a.m. with RN B during a Neupogen (a med used for chemotherapy patients to increase the white blood cell count) subcutaneous (into the skin) injection with patient 31 (who had just started chemotherapy treatments for cancer) revealed he:
*Drew up from the med vial into a syringe.
*Entered the patient's room with the med without washing or sanitizing his hands.
*Administered the med and had not washed or sanitized his hands.
*Had not worn gloves during the injection of the med.
*Did not performed any hand hygiene after the injection.

3. Interview on 7/23/14 at 8:30 a.m. with the director of nursing revealed:
*The nursing staff should have washed or sanitized their hands prior to and after IV and subcutaneous injections.
*The RN administering the subcutaneous injection should have worn gloves during the procedure.

Review of the provider's February 2014 Hand Hygiene policy revealed decontamination of hands with waterless antimicrobial hand rub or antiseptic soap and water for the following circumstances:
*Before having direct contact with patients.
*After contact with patient's intact skin.
*After contact with body fluids or excretions, mucous membranes, non-intact skin as long as the hands were not visibly soiled.

Review of the provider's February 2014 Standard Body Substance Isolation policy revealed:
*Decontaminate hands with alcohol-based waterless hand rub or antiseptic and water in the following circumstances:
*Before contact with the patient.
*Before caring for patients with severe neutropenia (low white blood cell count [white blood cells fight the bodies infections]) or other forms of severe immunosuppression (very low resistance to infections).







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4. Observation, interview, and label review on 7/22/14 at 1:30 p.m. with the contracted ultrasound technician E revealed:
*They used Metricide OPA Plus as a high level disinfectant for their vaginal probes.
*The Metricide OPA Plus was tested every time it was used with a Metricide OPA Plus test strip.
*Review of the label for the Metricide OPA Plus test strip revealed:
-The test strips were good for ninety days from the day the package was opened.
-The package of test strips had not been dated with the open date.
*She did not know when the test strips were opened and could not tell me if they were expired.
*She was not the normal technician for this facility. She was filling in for the normal technician who was on vacation.

5. Observation, interview, and record review on 7/22/14 at 9:40 a.m. with certified nursing assistants (CNA) C and D in the whirlpool room revealed:
*Two electric razors that were used on more than one person.
*The razors were cleaned daily when used.
*Review of the cleaning schedule revealed the razors were last cleaned on 7/20/14 during the day shift and had not been used since.
*Both razors had a moderate amount of white scaly debris around the blades of the flip out trimmer.
*They agreed the electric razors were not clean.
*They were not aware if the hospital had a policy on cleaning the razors.
*They were not aware the razors should have been cleaned between each patient.

Review of the provider's undated care of the electric razor policy revealed:
*"Electric and battery operated razors must be cleaned after each use."
*"After each use, detach razor head and brush all hair from head and drive section."
*"Inspect razor. If it appears to need additional cleaning, do so with alcohol wipes."
*There were no directions for disinfecting the razors.



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6. Observation on 7/22/14 at 9:55 a.m. of the radiology and CT rooms revealed several foam positioning wedges without cleanable surfaces or covers.

Interview on 7/22/14 at 9:55 a.m. and on 7/23/14 at 8:25 a.m. with the radiology manager revealed:
*She agreed the positioning wedges were not cleanable and could have been an infection control risk.
*The positioning wedges were covered with a pillowcase for use but had not been cleaned between patients.

Based on record review, interview, and policy review, the provider failed to ensure comprehensive care plans had been completed for two of three swing bed patients (5 and 6) with pain. Findings include:

1. Review of patient 5's medical record revealed:
*She had been admitted on 2/22/14 for comfort care only.
*She expired on 2/25/14.
*She had diagnoses of acute cardiovascular disease, hemiparesis, and lung cancer with spread to the brain.
*She received morphine for her pain and to promote comfort.
*Her care plan had not addressed her pain.

2. Review of patient 6's medical record revealed:
*She had been admitted on 5/2/14 and discharged on 5/7/14.
*She had diagnoses of cellulitis (inflammation of tissue), shortness of breath, edema, and weakness.
*A pain assessment completed on 5/2/14 noted she had ongoing chronic intermittent pain.
*On 5/3/14 she rated her arthritic hand pain at 7 (ten being most severe).
*On 5/4/14 she had rated her hand pain at 4.
*On 5/5/14 she had rated her pain at 8:05 a.m. at 5, at 3:35 p.m. at 3, and at 7:25 p.m. at 5.
*On 5/6/15 at 1:02 p.m. she had rated her knee pain at 2 and at 7:15 p.m. her finger and hand pain at 5.
*On 5/7/14 at 8:15 a.m. she had rated both her hands pain at 4.
*Her care plan had not addressed her pain.

3. Interview on 7/23/14 at 10:00 a.m. with the director of nursing confirmed the care plans for patients 5 and 6 should have had interventions in place to address their pain.

4. Review of the provider's undated Nursing Care Plan policy revealed nursing care plans should be based on assessing the patient's nursing care needs and develop appropriate nursing interventions.