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Based on observation and staff interview, the facility failed to ensure drugs were stored in accordance with accepted professional principles and in an organized manner, for two of two sampled patients (Patient 1 and Patient 2).

These failures had the potential to result in the theft/loss or unauthorized use of a controlled substance. The disorganized crash cart could result in the delayed administration of emergency treatment to the patients.

Findings:

1. On 9/17/18 at 9:40 a.m., the crash cart [cart containing emergency medications and equipment used to treat, revive or rescue a patient having emergent life-threatening symptoms] was observed. Two vials of morphine sulfate (narcotic pain medication), 5 milligram (mg) per 1 milliliter (ml) was stored inside the crash cart's drawer. The crash cart was secured with a plastic seal that could be twisted and broken to open the cart. There was no key lock on the crash cart in order to secure the morphine.

During a concurrent interview, the Registered Nurse - Unit Supervisor (RN - US) stated the morphine was in the crash cart for emergency pain management.

On 9/19/18 at 2:05 p.m., the crash cart contents were counted against the crash cart content list with the Supervising Registered Nurse (SRN). The count revealed the crash cart contained 2 vials of morphine 5 mg/ml as listed in the crash cart content list.

The facility's Policy and Procedure titled, "Nursing Procedure - CONTROLLED DRUGS" dated 8/1/18, indicated "Certain drugs specified in the Federal Controlled Substance Act of 1970 [Regulates the manufacture, possession, use, distribution of certain narcotics... such as morphine...] are controlled and require a system for accountability... Controlled drugs are to remain in locked cabinet when not in use... keep separate from other drug storage..."

2. On 9/17/18 at 9:45 a.m.,the crash cart drawer contained medication with labels that had scratches and a sticky smudged substance that appeared to be old tape. Drug names on two labels were faded and difficult to read, and three epinephrine (drug used to treat severe allergic reactions to insect stings or bites, foods, drugs, and other allergens) was stored inside the top drawer with the bar codes facing up and the name/label was not visible.

During a concurrent interview, the Registered Nurse - Unit Supervisor (RN - US) stated the pharmacist checked the crash cart each time the lock was broken and at least monthly. She stated the pharmacist was responsible to ensure medication was properly labeled and easy to read.

On 9/19/18 at 1:20 p.m., Pharmacist 1 stated, the crash cart medication drawer should have contained the required medication and supplied with clear and visible labels.

On 9/19/18 at 2:40 PM, Registered Nurse (RN) 1 stated, during a mock code earlier that day she was unable to quickly find the Epinephrine. She stated the Epinephrine was stored backwards and the label was not visible.

On 9/19/18 at 3:15 PM during an interview, the Medical Director stated, "... The Governing Body had the ultimate responsibility in overseeing the accurate implementation of all Policies and Procedures... to provide immediate and efficient response to medical emergencies. He stated the crash cart was not organized to sufficiently and promptly meet the emergency needs of the patients."

The facility's Policy and Procedure titled, "Emergency Medication" dated 12/17 indicated, "... The top drawer of the Emergency Carts must be inspected and sealed with a numerical yellow pharmacy seal monthly and when opened. The pharmacist is responsible for verifying the contents and resealing the cart."

The facility's Policy and Procedure titled, "Crash Cart/Cardiac Monitor/Defibrillator" dated 3/18/18 indicated, "...Will have an emergency care (Crash Cart) stocked with emergency drugs/supplies in order to enable the nursing staff to respond quickly and efficiently whenever a medical emergency occurs."

Based on observation, interview, and record review, the facility failed to ensure the kitchenette, x-ray room, and laboratory were maintained to ensure an acceptable level of sanitation, safety, and quality for two of two sampled patients (Patient 1 and Patient 2).

These failures had the potential to result in cross-contamination and placed the patients at risk for acquiring infections.

Findings:

1. On 9/17/18 at 9:20 a.m., during an initial tour, the facility's kitchenette was observed with the following:

a) Utensils (spoon, fork and tongs, towels, spatula and paper cups) were kept in a stained drawer with dust and dirt debris.

b) Plastic liquid containers had scratched and discolored surfaces and had sticky tape marks all over the outside part of the container.

c) Sixteen packets of thickeners had expiration dates of 2001, 2002, 2003, 2015 and 2016.

On 9/17/18 at 9:55 a.m., during an interview, the Registered Nurse (RN) stated, the utensils in the drawer were for patients' use. She stated the spoon was used for mixing thickener for the patients. She stated the plastic liquid containers, which were in poor condition and appearance, were used to contain the patients' drinking water and feeding and medication flushes. When asked about the thickeners, RN stated, "The thickeners are for the patients... they are expired..." RN confirmed one packet of thickener expired in 2001, six packets expired in 2002, one packet expired in 2003, six packets expired in 2015, and 2 packets expired in 2016. RN stated, "Let me throw these away... That's not good if the patient consumes these expired thickeners."

The online information at https://www.thickit.com indicated, "Thickeners are safe to use for 12 months after its manufacture date, either opened or unopened shelf life. After 12 months, the product may not thicken as efficiently."


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2 a) On 9/17/18 at 9:50 a.m., a tour of the facility was conducted with the Chief of Plant Operations (CPO). A suction machine was observed stored inside the shower room. A connecting tube was inside an open plastic bag with dust particles. The CPO stated the suction machine and tubing had been placed in the shower room to use on patients needing suctioning.

2 b) On 9/17/18 at 10:35 a.m., a tour of the Radiology Department's x ray room was conducted with the CPO and the Supervising Registered Nurse (SRN). A suction machine was observed stored near the x-ray bed. A connecting tube was outside the open plastic bag with dust noted on the tubing. The Senior Radiology Technician (SRT) stated, "That is how it has always been for a long time." The SRN prompted the SRT to dispose of the connecting tube and replace it with a new one. When asked what the standard of practice was for infection control, the SRN stated, "The suction machine should be clean and the connecting tubing should be inside a closed plastic bag."

The facility's Policy and Procedure (P & P) titled, "SUCTIONING" dated 4/1/17, indicated "... Suction machines that are in common areas... will be cleaned... When a machine is not in use, it should be kept clean and ready for use.

3. On 9/17/18 at 10:12 a.m., a concurrent observation and interview was conducted with the the Laboratory Supervisor (LS). The laboratory freezer stored multiple vials of reagents next to two blood speciment tubes with light yellow color substance. The blood speciment tubes were inside 2 clear plastic bags marked "BIOHAZARD SPECIMEN."

On 9/17/18 at 1:40 p.m., during an interview, the LS stated the two test tubes were [random] patient's blood serum specimen being saved for future use in case the physician ordered a repeat test. She stated it had been the facility's practice to store all [human] specimens marked "biohazard" in the laboratory freezer with all the reagents. When asked to provide the Policy and Procedure (P & P) that supported this practice, the LS stated, "We don't have a written P & P on where blood products/specimens and/or biohazard substances should be stored..."

On 9/17/18 at 2:50 p.m., during an interview, the Medical Director (MD) stated, "When it is a biohazard, it has to be [stored] in a separate area."

The facility's P & P titled, "INFECTION CONTROL GUIDELINE: Standard Precautions" with a revision date of 12/15 indicated "...Laboratory specimens from all clients are handled as potentially infectious and shall be placed in the clear bio-hazardous specimen plastic bag and transported to the infectious waste disposal area... All blood will be considered infectious regardless of the perceived status of the source individual... The Medical Director has the ultimate responsibility and authority for ensuring that precaution policies are followed and that correct procedures are maintained by all levels of personnel... All personnel are responsible for complying with precaution policies..."

The United States Centers for Disease Control (US - CDC) [www.cdc.gov] dated 2017, indicated "... Consider all plasma or serum specimens potentially positive for infectious material... place in a biohazard bag and keep these bags in appropriate containers until disposal..."